Journey to the inside
Thresholds, April 2023

Psychotherapist, Tracy Northampton, is a patron of the Body Dysmorphic Disorder Foundation. The organisation works to raise awareness of this condition, which can be difficult to spot and diagnose, even for experienced mental health professionals. Natasha Silver Bell is the founder of Silverbell Coaching Global. They talk here about their different approaches.

What characterises body dysmorphic disorder (BDD)?

Tracy: It is a physical experience which manifests as a sense of shame about a particular body part. Individuals with BDD are often focused on one or more perceived flaws in their appearance, such as their skin, nose or eyes, but it could be about their whole body. There’s a perceived sense of something being wrong, and the person thinks that going to a cosmetic surgeon or a dermatologist, rather than a mental health practitioner, is what is needed. The condition involves a hatred of the self, which can prevent people from openly sharing and exploring their experiences. There is also a disconnect with the feelings and emotions inside. Everything becomes projected onto the body part.

Natasha: BDD is not an eating disorder. This is an important distinction, because the lines can get very blurred. A young person with BDD may feel that their waistline isn’t thin enough, which then might result in restricting food intake; but it’s not an eating disorder. There are other ways body imaging can distort the lens. Someone struggling with BDD might fixate on their elbow or nose, and they may go to a cosmetic surgeon to ‘correct’ the perceived imperfection.

Tracy: Quite a few people come into therapy with that confusion. There is quite an overlap between the two, but BDD is often a real fixation on a body part. It relates to the way that somebody manages the emotions and feeling states around what they see in the mirror. It could be that one of the ways that they are dealing with the internal stress about this is through food. They could be over-exercising. They could be using very potent OCD behaviours to try to self-regulate and manage the distress about what they see in the mirror.

How might you work with this therapeutically?

Tracy: I work as an integrative psychotherapist, so I use humanistic, psychodynamic and behavioural techniques to support the individual. Fundamentally, I come from a place of empathy, meeting that person in a place of total respect and positive regard. I listen to a multitude of elements. We start by exploring how the client has felt about themselves and their body since childhood. We work with that and then we look at what the shifts were and what started to change. A lot of the time, it is a result of different types of trauma, or a single trauma. It could be bullying at school. There are so many different elements. Then there’s a lot of reframing, so I use behavioural techniques. The recommended, evidence-based treatment is CBT with exposure and response prevention. The basis of any work is creating a supportive, empathic and encouraging relationship.

Natasha: Coaching dovetails the clinical work. As therapists are diagnosing and treating a patient, coaches function as what Peter Levine calls ‘the empathetic witness’.¹ Sometimes, it’s not in what we say, it’s in what we don’t say. The coach acts as a quiet, observational, compassionate witness. Coaches have overcome their own adversity, and their familiarity with the clients’ unspoken language of struggle is extremely valuable. Although dialectical behaviour therapy is the foremost recognised treatment for working with personality disorders, DBT can also be an important modality for use with BDD. It helps to move clients with BDD into their own awareness and can help them to self-regulate when they are emotionally activated.

What does BDD do to a person’s sense of self?

Tracy: The individual comes to therapy because their internal world is thwarted, and they are disconnected from a true sense of who they are. Winnicott wrote about the false self and the true self,² and I do refer to that quite a lot. My work is about connecting them back to the core of who they are, which is where spirituality can come in. 

BDD can be self-orientated, and the individual can become very encapsulated in their world. Clients can find it difficult integrating and being within groups of people. Being seen is probably one of the most terrifying things. Part of the healing process, and movement forward, is helping that person to re-enter life. Many of them become really isolated. I would support clients to go to a class, group or training, or explore the possibility of attending one of the online BDD support groups that the Body Dysmorphic Foundation offers.³ People don’t have to show themselves on the screen, but hearing and talking to other people who are suffering from this does dilute the sense of shame they feel.

Natasha: Compassion is the most important ingredient. You can have great clinical or coaching training and know how to treat and support, but if you don’t lead with compassion, then all of that is for nothing.

Tracy: I think that is key because we are talking about a condition where somebody feels a million miles away from self-compassion. There is a high suicide rate with BDD. Part of the reason I got into the field and connected with the foundation is because somebody very dear to me in the family, my niece Charlotte, was suffering from it for quite a long time. This was during a period when it was very misunderstood and there wasn’t a clear diagnosis. Unfortunately, she didn’t get the support she needed. I am keen to support clinicians to understand the condition better. It’s important that the individual gets support at an early stage, before it escalates.

To what extent is BDD a spiritual issue?

Tracy: I think what we are looking for in healing is a rediscovery of something that has perhaps always been there. When we come into the world, we are pure, and we are perfectly imperfect. It’s about rediscovering that the innate goodness and beauty of the self and the intrinsic worth of the human being are completely unrelated to the physical appearance and to the body.

Natasha: As coaches, we are trying to break through the noise and get to the core. It is also about modelling a peaceful, calm state of mind. That creates curiosity in the person to ask: ‘OK; how are you doing that?’ At that point, a coach may talk about meditation and spirituality.

How might you work with the spiritual aspect?

Tracy: BDD can be existential in nature, including questioning whether one deserves to exist, or whether the self is the physical body, or more than the physical body. It can be useful to perhaps explore this in terms of embodied spirituality, looking at questions such as who and what the self is, and what role the physical body plays in this. It can also help to encourage creative, artistic, right-brain connection, enabling the person to connect with the heart. Drawing on my own journey, and seeing others in real conflict about what’s happening inside, I know that creativity is important when it comes to spiritual healing and connecting to the soul. It’s a whole raft away from the external, physical ‘how I look’. Art is a real journey to the inside – a rediscovery of the heart and soul.

Natasha: Being silent and present in nature is also so important.

Are there aspects of faith and spirituality that can be damaging, or have impacted clients who have this condition?

Tracy: Deep depression can often lead to a lack of hope or faith. Clients may believe, for instance, that there cannot be a loving God who would create them to be so hideous. Some religious ideas, such as the Catholic concept that we are born in sin, may add to the felt sense of shame. This could have informed a person’s sense of self from a young age. The fasting that takes place in some religions may also complicate and exacerbate eating difficulties. In these cases, it can be about supporting the client to refind and reconnect to a sense of self that goes beyond the physical.