Narrative therapy is proposed as an effective treatment for body dysmorphic disorder A case example illustrates the clinical application. Implications for the theory and practice of body dysmorphic disorder are considered.
Body dysmorphic disorder (BDD) is a complex clinical syndrome that each year affects approximately 2% of the population in the United States (Phillips, 2005a). According to the Diagnostic and Statistic Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR; American Psychiatric Association [APA], 2000), BDD is described as a preoccupation with an imagined defect or slight physical defect in appearance that results in significant distress or impairment in important areas of functioning. Clients with BDD .experience a variety of problems and symptoms, including poor self-image, depression, anxiety, avoidance of social situations, and seeking repeated cosmetic surgery for the perceived appearance defect (APA; Renshaw, 2003). Various etiologic theories for BDD have been set forth, including cognitive-behavioral (Sarwer, Gibbons, & Crerand, 2004), neurobiological (Hadley, Newcorn, & Hollander, 2002; Phillips, 2005b), and sociocultural (Phillips, 2005a; Rivera & Borda, 2001). It has been suggested that the most effective treatment approaches for BDD include cognitive-behavioral and antidepressant medication administration (Phillips, 2005a, 2005b; Sarwer et al.).
In this article, we propose that narrative therapy provides an effective framework to treat BDD. An increasing number of counseling, family therapy, and psychotherapy models have emphasized a narrative approach to conceptualizing problems and change. The pioneering narrative model was developed at the Dulwich Therapy Center in Australia (White, 1995, 1997, 2000, 2004; White & Epston, 1990). For purposes of this article, narrative therapy hereafter refers to the model developed at the Dulwich Therapy Center. Influenced by postmodernism (Lyotard, 1984) and the philosophy of Foucault (1987), narrative therapy conceptualizes clients' problems as restraining narratives that are influenced by one's culture (White & Epston). The change process in narrative therapy involves helping clients replace their restraining narratives with more preferred stories about their problems and lives (White, 2000; White & Epston).
We have found narrative therapy to be a fitting model for BDD for several reasons. First, this approach speaks to the sociocultural factors that are presumed to influence clients with BDD (Phillips, 2005a). Second, narrative therapy has already been successfully applied to anorexia nervosa (Maisel, Epston, & Borden, 2004; Nylund, 2002), a disorder that has features similar to and/or is often comorbid with BDD (Grant, Kim, & Eckert, 2002). Third, narrative therapy is an empowering, focused, and strength-based model and, therefore, holds promise as a potentially effective approach for working with clients with BDD. Narrative therapy offers an alternative to the prevailing cognitive-behavioral therapy approaches to BDD that tend to emphasize faculty cognitions and create resistance during the change process (cf. Phillips; White & Epston, 1990). Moreover, Sinclair (2006) has suggested that "narrative therapy ... invites clients to reflect on the influence of culture and, thus, represents an important contribution for helping women with body related concerns" (p. 64). To date, however, no narrative therapy application specific to BDD has been found in the literature. Due to the relatively high incidence of BDD, we expect that most mental health counselors will at some time encounter clients who suffer from this condition. Accordingly, it is important for mental health counselors to develop effective treatment strategies for BDD. In this article, we describe our application of narrative therapy to BDD in hopes of providing mental health counselors with a basis from which to intervene.
The organization of this article is as follows. First, we describe BDD along with a consideration of various issues pertaining to this disorder, including comorbidity, etiology, and treatment. Next, we describe the theory and practice of narrative therapy. Then, we provide a case example that illustrates the application of narrative therapy to work with individuals diagnosed with this disorder. Finally, we discuss implications pertaining to the theory and practice of narrative therapy in relation to BDD.
BODY DYSMORPHIC DISORDER
BDD is classified in the DSM-IV-TR as a somatoform disorder (APA, 2000). The DSM-IV-TR criteria for BDD are as follows: (a) "preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive"; (b) "the preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning"; and (c) "the preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)" (APA, p. 510). BDD is often occasioned by maladaptive behaviors such as frequent checking of the perceived defect in mirrors; avoidance of reflective surfaces; social inhibition; frequent consultation with dermatologists, cosmetic surgeons, or performing dangerous self-surgeries; and suicide (APA). BDD usually first appears during adolescence and the disorder does not appear to be gender specific (APA; Phillips & Diaz, 1997). The prevalence rate of BDD has not been firmly …