Motivating People with BDD to Participate in Treatment

Many individuals with BDD who enter the office of a mental health professional do so hesitantly. They are experiencing a variety of distressing emotions, including shame, self-disgust, hopelessness, depression, anger, and anxiety. In all likelihood, they do not believe psychological treatment is the solution to their problem. Their families may be in similar distress, as they may not understand their loved one’s preoccupation with appearance. All of these factors present a challenge to therapists who treat BDD.

Motivation is a necessary part of any treatment protocol, but it is especially important in those who present with lower insight into their condition. Insight in BDD is quite low compared to related disorders. Studies have shown that up to 60% of those with BDD have beliefs reaching delusional level. Many individuals with BDD have fluctuations in their insight level, strongly believing in the existence of their flaw one day and believing they look okay on other days. Treating individuals with BDD requires a compassionate, patient, and flexible approach.

Motivational interviewing, developed by Miller and Rolnick, provides many effective techniques. The techniques are aimed at developing a collaborative and empathetic relationship with the client. With encouragement from the therapist, the client identifies his or her own reasons for change. Motivational interviewing techniques incorporate reflective listening techniques. Therapists do not directly dispute the person’s beliefs; instead, they stress the person’s ability to change and develop a non-judgmental supportive relationship. These techniques can be helpful even within the change-oriented techniques of cognitive and behavioral therapy. These techniques are best learned by becoming familiar with Miller and Rolnick’s research.

Strategies to help engage your client in treatment:

  • Be flexible with session format: If severe, an individual with BDD may not be able to sit in a crowded waiting room or see you during the day. Accommodating these obstacles will increase the likelihood of your client engaging in treatment beyond the first consult.
  • Do a thorough assessment of motivation: Conduct a thorough initial assessment of motivation level starting with why the individual sought therapy and their history of cosmetic and dermatological treatment.
  • Assess other treatment obstacles: Assessing depression, suicidal thoughts, degree of avoidance of daily life activities, as well as strong or delusional beliefs will guide your treatment plan. These may need to be addressed and improved before incorporating behavioral therapy techniques.
  • Gather thorough psychosocial history: Gather an extensive psychosocial history, probing for bullying, teasing, abuse, family values, and societal messages about beauty and physical appearance. Provide your client with an understanding of how these factors shaped their views about the importance of appearance.
  • Provide education regarding theories of BDD development: Psychoeducation about the condition should include a review of the visual perceptual research, explaining that BDD may be a result of a distortion in the way someone with BDD’s brain processes visual information. Present the diathesis-stress model to explain the etiology of BDD. Explain how genetics and biology along with environmental factors may have contributed to the development of the disorder. Provide clients with explanations on how their compulsive and avoidance behaviors maintain the disorder. 
  • Learn how BDD has impacted their life: Make a list of the ways in which the focus on appearance has negatively impacted the person’s life. Individuals with BDD have a lower quality of life than individuals with chronic medical and psychiatric conditions.
  • Have them make a list of what their life would be like without BDD: Ask your client to imagine how their life would be without BDD. Make a list of what would be different. 
  • Have the client make a list of life goals: Help your client make a list of their life goals. Discuss how the focus on appearance has interfered with attaining these goals. Develop a specific action plan to accomplish the smaller or reachable goals to motivate and instill hope. Use problem solving and pro/con worksheets to help address obstacles to achieving these goals. 
  • Complete a pro/con list of getting well: Develop a list of the pros and cons of getting well. What obstacles will your client face as they get well, and how can they overcome them?
  • Develop a list of treatment goals: Develop a collaborative list of treatment goals to address immediately. An individual with BDD may not be able to decrease mirror checking or the use of cosmetic products in the beginning stages of treatment. They may agree instead to decrease their isolation and avoidance of daily life activities. Be flexible with your treatment plan. Be willing to alter it as necessary.
  • Avoid direct disagreements about the perceived defect: An individual with BDD truly sees their body part in the way they describe. Minimizing their perceptual experience will only disrupt the therapeutic relationship. It is best to acknowledge that although others may not see it, they do. Focus instead on how the preoccupation is negatively impacting their life.
  • Be willing to discuss cosmetic surgery: Some individuals with BDD think about or seek cosmetic and dermatological procedures frequently. It may seem strange, but be open to discussing these thoughts with your client. Families and friends may have refused to discuss surgery with their loved one. A therapist willing to take their concerns seriously can be a relief to someone with BDD. Discussing the desire for BDD does not mean you are condoning it. A non-judgmental approach allows you and your client to thoroughly explore his or her expectations for the procedure and offers an opportunity to discuss the psychological risks of these procedures on the long-term outcome in BDD. If your client has scheduled consultations for surgery, offer to go to the appointment together.
  • Use cognitive therapy interventions: Cognitive therapy is best aimed at challenging the client’s underlying core beliefs about the importance and value of appearance. A client with BDD may believe that they can’t be happy unless they look a certain way. Identifying and addressing these distortions in thinking is more effective than disputing the existence of the perceived flaw.
  • Work with families: Families provide a wealth of important life history and information about the person’s current environment. Working with families to improve their reaction to the BDD may help motivate your client to change. As in OCD, families with BDD may vacillate between over-accommodation and anger toward their loved one. Providing support and education to families may reduce your client’s daily distress.

If you are successful in implementing the above strategies and you have a client now ready for treatment please click here for an overview of and guide for conducting cognitive behavior therapy for BDD. Additionally, please click here for information regarding medication treatment for BDD.

by Sony Khemlani-Patel, PhD