Adult Treatment Planner

Objectives and Interventions

• Verbalize negative feelings regarding body and discuss self-prediction of catastrophized consequences of perceived body abnormality.
  • Build a level of trust and understanding with client by listening to his/her initial complaints without rejection or confrontation.
• Discuss causes for emotional stress in life that underlie the focus on physical complaints.
  • Refocus the client's discussion from physical complaints to emotional conflicts and expression of feelings.
  • Explore the client's sources of emotional pain - feelings of fear, inadequacy, rejection, or abuse.
  • Assist the client in acceptance of connection between physical focus and avoidance of facing emotional conflicts.
• Identify family patterns that exist around exaggerated focus on physical maladies.
  • Explore the client's family history for modeling and reinforcement of physical complaints.
• Verbalize the secondary gain that results from physical complaints.
  • Assist the client in developing insight into the secondary gain received from physical illness, complaints, and the like.
• Identify causes for anger.
  • Explore for causes for the client's anger.
• Express angry feelings assertively and directly.
  • Using role-playing and behavioral rehearsal, teach the client assertive, respectful expression of angry feelings.
  • Train the client in assertiveness or refer him/her to an assertiveness training class.
  • Reinforce the client's assertiveness as a means of him/her attaining healthy need satisfaction in contrast to whining helplessness.
• Identify the connection between negative body image and general low self-esteem.
  • Probe the client for causes for low self-esteem and fears of inadequacy in his/her childhood experiences.
  • Teach the client the connection between low self-esteem and preoccupation with body image.
• Increase social and productive activities rather than being preoccupied with self and physical complaints.
  • Assign the client to develop a list of pleasurable activities that can serve as rewards and diversions from bodily focus.
  • Assign diversion activities that take the client's focus off himself/herself and redirect it toward hobbies, social activities, assisting others, completing projects, or returning to work.
• Implement the use of relaxation skills and exercise to reduce tension in response to stress.
  • Train the client in relaxation techniques using biofeedback, deep breathing, and positive imagery techniques.
  • Assign the client to a daily exercise routine.
• Decrease physical complaints, doctor visits, and reliance on medication while increasing verbal assessment of self as able to function normally and productively.
  • Challenge the client to endure pain and carry on with responsibilities so as to build self-esteem and a sense of contribution.
  • Structure specific times each day for the client to think about, talk about, and write down his/her physical problems while outside of those times the client will not focus on his/her physical condition; monitor and process the intervention's effectiveness (or assign "Controlling the Focus on Physical Problems" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma).
  • Create an ordeal (i.e., a specific task that is necessary in the client's daily life but one that he/she finds unpleasant) for the client to do each time the symptom (physical complaint) occurs; convince the client of the effectiveness of this prescription and monitor for compliance and results.
• Poll family and friends regarding their concern about physical complaints.
  • Assign to the client the ritual of polling spouse, friends, neighbors, pastors, and so on about how concerned they feel he/she should be, and what they would recommend he/she do each time a physical complaint/concern occurs. Process results.
• List coping behaviors that will be implemented when physical symptoms appear.
  • Ask the client to try to predict the next attack or physical issue and then plan how he/she will cope with it when it comes.
• Report on instances of taking active control over environmental events versus passively reacting like a victim.
  • Empower the client to take control of his/her environment rather than continuing in his/her attitude of helplessness, frustration, anger, and "poor me."
• Engage in normal responsibilities vocationally and socially without complaining or withdrawing into avoidance while using physical problems as an excuse.
  • Reframe the client's worries into a metaphor of "making sure he/she stays healthy." Then issue a prescription and a plan for implementing increased exercise, sex, or joy.
  • Give positive feedback when the client is symptom-free and accepting of his/her body as normal and healthy.
  • Discuss with client the destructive social impact that consistent complaintive verbalizations or negative body focus have on friends and family.
• Accept referral to a pain clinic to learn pain management techniques.
  • Refer the client to a pain clinic.
• Cooperate with an evaluation by a physician for psychotropic medication for Body Dysmorphic Disorder.
  • Arrange for an evaluation for a prescription of psychotropic medications (e.g., SSRIs).
  • Monitor the client for prescription compliance, side effects, and overall effectiveness of the medication; consult with the prescribing physician at regular intervals.
• Participate in exposure and ritual prevention therapy for Body Dysmorphic Disorder.
  • Enroll the client in a small closed-enrollment group for exposure and ritual prevention therapy for Body Dysmorphic Disorder (see "Cognitive Behavior Group Therapy for Body Dysmorphic Disorder: A Case Series" by Wilhelm, Otto, Lohr, et al. in Behavior Research and Therapy, 1999, Vol. 37, pp. 71-75), or conduct the therapy individually.
• Verbalize an understanding of the rationale for treatment.
  • Educate client about the role of biased fears and avoidance in maintaining Body Dysmorphic Disorder; discuss how treatment serves as an arena to desensitize fears, to reality test fears and underlying beliefs, and build confidence in self-acceptance of his/her appearance.
• Identify and replace biased, fearful self-talk and beliefs.
  • Explore the client's schema and self-talk that mediate his/her self-conscious fears and related avoidance behavior; assist him/her in generating thoughts that challenge and correct for the biases (or assign "Negative Thoughts Trigger Negative Feelings" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma).
• Undergo repeated imaginal exposure to feared external and/or internal cues.
  • Assess external triggers for fears (e.g., persons or situations) and subtle and obvious avoidant strategies (e.g., wearing concealing clothing, only going out at night).
  • Direct and assist the client in construction of a hierarchy of fear triggers; incorporate exposures that gradually increase the degree to which the client hides his/her appearance.
  • Select initial exposures that have a high likelihood of being a successful experience for the client; be a participant model and do cognitive restructuring within and after the exposure.
• Complete homework assignments involving in vivo exposure to feared external and/or internal cues.
  • Assign the client a homework exercise in which he/she repeats the exposure between sessions and records responses (or assign "Gradually Reducing Your Phobic Fear" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma); review during next session, reinforcing success and providing corrective feedback toward improvement.
• Implement the use of the "thought-stopping" technique to reduce the frequency of obsessive thoughts.
  • Teach the client to interrupt critical self-conscious thoughts using the "thought-stopping" technique of shouting STOP to himself/herself silently while picturing a red traffic signal and then thinking about a calming scene.
  • Assign the client to implement the "thought-stopping" technique on a daily basis between sessions (or assign "Making Use of the Thought-Stopping Technique" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma); review.
• Implement maintenance strategies for managing possible future anxiety symptoms.
  • Identify and rehearse with the client the management of future situations or circumstances in which lapses could occur.
  • Instruct the client to routinely use strategies learned in therapy (e.g., continued exposure to previously feared external or internal cues that arise) to prevent relapse into critical self-conscious fears and avoidance patterns.
  • Schedule periodic "maintenance sessions" to help the client maintain therapeutic gains.