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Treating Displacement, Teasing, and Familial
Expectations with a 'Family Values' Exercise
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In the last section, we discussed three concepts of BDD in child clients. These three concepts of BDD in child clients included: characteristics; long-term consequences; and adolescence.
Although some clients develop BDD in later adulthood, I have found that the root causes of many of my clients BDD occurs in childhood, related to events that transpired to ignite the idea of worthlessness and low self-esteem.
In this section, we will examine three theories related to the root causes of BDD. These three concepts related to the root causes of BDD include: displacement; teasing; and familial expectations.
3 Theories of the Cause of BDD
♦ 1. Displacement
The first theory related to the root causes of BDD is displacement. Some researchers have suggested that BDD arises from the unconscious displacement of sexual or emotional conflict, or, more specifically, feelings of inferiority, guilt, or poor self-image. This displacement process is presumed to occur because the underlying emotional problem is too threatening or anxiety provoking to be dealt with more directly. The client transfers the guilt or self-consciousness related to a more general area and tunnels his or her feelings to a more specific body part. However, there is little evidence supporting this theory and many therapists contend that BDD has more to do with feelings related to appearance rather than underlying sexual distress.
♦ 2. Teasing
The second theory related to the root causes of BDD is teasing. About 60% of clients with BDD report frequent or chronic teasing about their appearance during childhood or adolescence. This teasing often focused on the body areas they later became obsessed with, but sometimes focused on other body areas.
The initial feelings of humiliation might force a client to focus on the body part. However, it’s also possible that people with BDD haven’t been teased any more than others, but that they’re more sensitive to teasing and feelings of inferiority. If a client is more sensitive, he or she would obviously be more susceptible to BDD and be more likely to focus on their appearance.
Although teasing may be the main root cause for some clients, others report very little teasing in their childhood. Nonetheless, I believe that teasing may make a client more likely to develop BDD at some point in their life. If the client is already at high risk due to other emotional causes, teasing seems to trigger BDD onset.
♦ Case Study: Shelly
Shelly, age 30, stated that although the teasing she experienced earlier in life was not specifically directed at her appearance, she interpreted it in that way. Shelly stated, "I was always the scapegoat in my class. Boys would mockingly ask me out while the popular girls tittered behind me. I didn’t know why they hated me so much, so I decided that it must be how I looked. Mostly, I thought it was my skin. I hated my acne and so I focused all my attention on improving my skin."
As you can see, even though Shelly had not been specifically teased about her skin, she still believed that the reason she was teased. This may indicate that it is not the teasing of the body part itself, but rather the teasing itself that causes clients to focus on their appearance in an attempt to compensate for what they believe they are lacking. Think of your Shelly. Was he or she teased in early childhood?
♦ 3. Familial Expectations
In addition to displacement and teasing, the third theory about the origins of BDD is familial expectations. Some clients report that their family’s emphasis on appearance and perfectionism contributed to their focus on appearance. Experiences such as these could lead to cognitive distortions, for example that one’s worth as a person is based only on one’s appearance.
BDD by Proxy
Occasionally, BDD symptoms seem to begin with a parent’s excessive preoccupation with their child’s appearance. This is known as "BDD by proxy." Other clients report feelings of neglect and rejection from caretakers and parents. However, it’s unclear whether these clients actually received less love and care from their parents or whether they were unusually sensitive to criticism or rejection at a young age.
Terry, age 33, stated, "In my childhood, people doted on my appearance. So I fear if I look bad, people won’t like me. The only area to get positive feedback from my parents was through my attractiveness. So destroying my appearance was the most destructive thing I could do." Terry’s parents had instilled the idea that her worth was directly connected to her appearance. If her appearance was not perfect, than her feelings of worthlessness increased. Obviously, this is an impossible task because no person’s appearance is perfect and a client overly preoccupied with his or her appearance will always find defects in his or her looks.
Think of your Terry. How has his or her parents instilled ideas of attractiveness and perfection in his or her mind? Also recall 5 year old Jimmy from the last section that was concerned about his "pot belly" and hair. Clearly finding the sources for these ideas implanted in a 5 year olds psychi. Did they come from a parent, sibling, relative, neighbor, day care work, television?
♦ Family Values Exercise
To help clients like Shelly and Terry, I ask that they try the "Family Values" Exercise . I ask them to start by making a list of the family values they’ve uncovered throughout therapy. Terry wrote:
1. It’s important to show off your looks in front of relatives and friends
2. If you’re pretty you’ll be popular
3. Be careful so nothing happens to your body
I then ask the clients to consider these values and to evaluate which ones get in the way of how they want to see themselves. Next, I ask them to construct some counterarguments that refute the truth of these attitudes that they’ve been taught since early childhood. Terry stated, "People aren’t hired on looks alone and ultimate judgments are reserved for actual characteristics, not appearances." I told Terry to rehearse these counterarguments out loud until they have made sense to her. Think of your BDD clients. Would they benefit from the "Family Values" Exercise?
In this section, we discussed three theories related to the root causes of BDD. These three concepts related to the root causes of BDD included: displacement; teasing; and familial expectations.
In the next section, we will examine three triggers of BDD symptoms. These three triggers of BDD symptoms include: comments; stress; and grudges.
What are three theories related to the root causes of BDD?
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