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Trauma-Informed and Embodied Approaches to Body Dysmorphic Disorder
Covering a range of embodied, trauma-informed approaches such as Acceptance and Commitment Therapy, Compassion-Focused Therapy, Eye Movement Desensitization and Reprocessing, mindfulness and yogic practices, this guide addresses the impact of trauma and shame in the development of body dysmorphic disorder.
The chapters are written by professionals in the field and experts-by-lived-experience and feature practical exercises and activities designed for use in therapy.
The chapters are written by professionals in the field and experts-by-lived-experience and feature practical exercises and activities designed for use in therapy.
250 pages, Kindle Edition
Published July 21, 2023
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April 27, 2024
I read this awhile back and only got halfway through it (to Chapter 8), but I took many notes that may benefit others who have partners or friends with body dysmorphia disorder (BDD).
A wide range of therapies are explored here, so if one doesn't help, you can try another. The book touches on eye movement desensitisation and reprocessing (EMDR), attachment theory/developmental psychology, relational psychoanalysis, neuroscience, non-violent resistance (NVR), yoga, polyvagal theory, acceptance and commitment therapy (ACT), compassion-focused therapy (CFT), nutrition, and voice dialogue. If you're interested in a specific framework, just leave a comment. I'm gonna focus on BDD so we don't get lost in epistemology.
Symptoms and Causes
It's widely agreed upon that body dysmorphia is driven by shame, an understanding of one's body as repulsive, and therefore a site of rejection from others. Healthy shame is adaptive, it alerts us to our social transgressions and motivates us towards repairing such ruptures. While this sounds inherently conservative, repair can occur through a transformation of the social field so that one's behaviours aren't perceived as shameful by others. Body dysmorphia, however, is driven by unregulated/unrepaired shame. Rather than direct us towards repair, such shame dysregulates. If we're raised by good-enough caretakers, we'll develop secure attachments to them, and shame will operate to inform us of how we've erred. If our caretakers are abusive or neglectful, shame will be experienced as catastrophic. Rather than reach out, we'll lash out, hide, dissociate, or plead. In other words, we'll be triggered towards a sympathetic response of fight, flight, freeze, or fawn.
It may sound strange that a child abused by a caretaker would internalise such an encounter through shame. It's theorised that this occurs because a child is at the mercy of their caretaker. Despite the abuse, the child needs their caretaker in order to survive. To blame the caretaker would be death, so the child blames themselves and does everything in their power to avoid their caretaker's violence. This kind of developmental trauma is indicative of those who develop borderline personality disorder (BPD), dissociative identity disorder (DID), and depersonalisation-derealisation disorder (DDD) (it's also common with masking and autism). As with BPD, DID, and DDD, body dysmorphia is experienced as an intense loneliness that cannot be overcome due to the intense fear of revealing oneself as defective. Intimacy is avoided out of a fear of rejection, yet such avoidance heightens the need for intimacy. Isolation is self-fulfilling, because it leads to reduced emotional mirroring—a reenactment of one's neglected childhood that reinforces isolation and feelings of deadness, emptiness, and mechanicity.
Specific to body dysmorphia is how shame—the internalised gaze of the other—is projected back out onto one's own body as a form of self-objectification. While self-objectification achieves a sense of control, one's attention is deflected from the site of trauma, which is too painful to confront and bear. In other words, triggers come to define and control us. Multiple contributors to this book warn against enabling the coping mechanisms of those who suffer from BDD. Though such coping mechanisms may mitigate short-term pain, they reinforce delusions reified onto physical traits. For example, disguising one's defect paradoxically generates the persistent threat of being exposed. Conversely, compulsively comparing one's features to normative others generates an endless source of hopelessness. I felt mixed reading these sections, because such arguments can be used to dismiss the importance of gender affirming care. At the same time, however, I know how delusional body dysmorphia can be, with no one seeing a defect in my face except me. I think the point is that self-transformation should be driven by care, rather than fear, of oneself and others. It should be sensuous and joyful, rather than harrowed by a phantom of the past we don't even want in our life.
Treatments
One method of treating body dysmorphia is through compassion-focused therapy. I learnt about CFT from a book on polyamory, and it boils down to changing one's relationship with one's internal voice(s). Those who've experienced trauma often have an internal critic who points out all the things they're doing wrong in their life. I used to respond to this voice with either sadboy melancholy or impotent resentment (over its persistent and undesirable existence). Compassion-focused therapy is about realising that the internal critic isn't trying to destroy your life, but rather inform you on the things you care about. If it's telling you that all your friends only tolerate your existence because they feel sorry for you, then it's telling you that you care deeply about your friends and that you desire more genuine interactions with them (something that you may be avoiding out of unrepaired shame). To put it differently, CFT attempts to attune you to the need that such thoughts express, and to be inquisitive rather than reactive towards distress.
Another method is to reframe certain behaviours associated with body dysmorphia through a more positive register. I'm not a huge fan of positive psychology, but the point is not so much to avoid negative traits, than to resignify them. For example, compulsive behaviours, which are characteristic of ADHD and autism as well, can be reframed as sites of self-direction and self-discipline. I used to hate myself for never being able to sustain an interest. I'd get fixated on a topic for a few months then bounce off and fall into a prolonged depression. When a friend told me that such behaviours were symptomatic of ADHD, I no longer felt defective. Shit made sense. Another tactic is to reorient compulsion towards non-appearance based traits, so that appearance is no longer the foundation of one's self-worth. For example, becoming fixated on making music creates a new avenue for objectification and control that isn't founded on inadequacy, but creativity.
This folds into somatic therapy, which seek to shift one's experience of the body from the visual register to the haptic one. Mindfulness, yoga, and dance can stimulate a joy for one's body and its capacities. A new sense of embodiment both informs one of traumas previously unknown and helps process such trauma into narrative memory so that it is no longer reexperienced, but rather retold. As before, objectification is redirected from estrangement to autonomy.
Lastly, non-violent resistance can help family members or friends reconnect with those suffering from body dysmorphia. This is a framework that understands blame (and dualistic thinking) as the source of interpersonal breakdown, and while its inadequacies become apparent when extrapolated to the political sphere, it's a good framework for identifying and undoing passive-aggressive bullshit, as well as encouraging vulnerability and honesty towards those you care about. As with compassion-focused therapy, non-violent resistance developed out of Buddhism and involves processes of de-escalation and reconciliation. Similar to transformative justice, the first step is a written statement of support towards the person experiencing body dysmorphia—that though friends and family have failed them in the past, they will continue to support them, to learn and grow and love, etc. The next step is an intervention, where grievances are aired and needs are expressed. This is necessarily a social event, so that the cycle of shame and withdrawal is interrupted. As with relational psychotherapy and narrative therapy, blame is avoided, emotions are validated (though not necessarily the actions they drive), and the family system itself is challenged as maladaptive, rather than any one person in it. The last step is reconciliation: in other words, a repair of the social through transformation.
This is unfortunately where my notes end, but hopefully they're helpful, nonetheless :)
A wide range of therapies are explored here, so if one doesn't help, you can try another. The book touches on eye movement desensitisation and reprocessing (EMDR), attachment theory/developmental psychology, relational psychoanalysis, neuroscience, non-violent resistance (NVR), yoga, polyvagal theory, acceptance and commitment therapy (ACT), compassion-focused therapy (CFT), nutrition, and voice dialogue. If you're interested in a specific framework, just leave a comment. I'm gonna focus on BDD so we don't get lost in epistemology.
Symptoms and Causes
It's widely agreed upon that body dysmorphia is driven by shame, an understanding of one's body as repulsive, and therefore a site of rejection from others. Healthy shame is adaptive, it alerts us to our social transgressions and motivates us towards repairing such ruptures. While this sounds inherently conservative, repair can occur through a transformation of the social field so that one's behaviours aren't perceived as shameful by others. Body dysmorphia, however, is driven by unregulated/unrepaired shame. Rather than direct us towards repair, such shame dysregulates. If we're raised by good-enough caretakers, we'll develop secure attachments to them, and shame will operate to inform us of how we've erred. If our caretakers are abusive or neglectful, shame will be experienced as catastrophic. Rather than reach out, we'll lash out, hide, dissociate, or plead. In other words, we'll be triggered towards a sympathetic response of fight, flight, freeze, or fawn.
It may sound strange that a child abused by a caretaker would internalise such an encounter through shame. It's theorised that this occurs because a child is at the mercy of their caretaker. Despite the abuse, the child needs their caretaker in order to survive. To blame the caretaker would be death, so the child blames themselves and does everything in their power to avoid their caretaker's violence. This kind of developmental trauma is indicative of those who develop borderline personality disorder (BPD), dissociative identity disorder (DID), and depersonalisation-derealisation disorder (DDD) (it's also common with masking and autism). As with BPD, DID, and DDD, body dysmorphia is experienced as an intense loneliness that cannot be overcome due to the intense fear of revealing oneself as defective. Intimacy is avoided out of a fear of rejection, yet such avoidance heightens the need for intimacy. Isolation is self-fulfilling, because it leads to reduced emotional mirroring—a reenactment of one's neglected childhood that reinforces isolation and feelings of deadness, emptiness, and mechanicity.
Specific to body dysmorphia is how shame—the internalised gaze of the other—is projected back out onto one's own body as a form of self-objectification. While self-objectification achieves a sense of control, one's attention is deflected from the site of trauma, which is too painful to confront and bear. In other words, triggers come to define and control us. Multiple contributors to this book warn against enabling the coping mechanisms of those who suffer from BDD. Though such coping mechanisms may mitigate short-term pain, they reinforce delusions reified onto physical traits. For example, disguising one's defect paradoxically generates the persistent threat of being exposed. Conversely, compulsively comparing one's features to normative others generates an endless source of hopelessness. I felt mixed reading these sections, because such arguments can be used to dismiss the importance of gender affirming care. At the same time, however, I know how delusional body dysmorphia can be, with no one seeing a defect in my face except me. I think the point is that self-transformation should be driven by care, rather than fear, of oneself and others. It should be sensuous and joyful, rather than harrowed by a phantom of the past we don't even want in our life.
Treatments
One method of treating body dysmorphia is through compassion-focused therapy. I learnt about CFT from a book on polyamory, and it boils down to changing one's relationship with one's internal voice(s). Those who've experienced trauma often have an internal critic who points out all the things they're doing wrong in their life. I used to respond to this voice with either sadboy melancholy or impotent resentment (over its persistent and undesirable existence). Compassion-focused therapy is about realising that the internal critic isn't trying to destroy your life, but rather inform you on the things you care about. If it's telling you that all your friends only tolerate your existence because they feel sorry for you, then it's telling you that you care deeply about your friends and that you desire more genuine interactions with them (something that you may be avoiding out of unrepaired shame). To put it differently, CFT attempts to attune you to the need that such thoughts express, and to be inquisitive rather than reactive towards distress.
Another method is to reframe certain behaviours associated with body dysmorphia through a more positive register. I'm not a huge fan of positive psychology, but the point is not so much to avoid negative traits, than to resignify them. For example, compulsive behaviours, which are characteristic of ADHD and autism as well, can be reframed as sites of self-direction and self-discipline. I used to hate myself for never being able to sustain an interest. I'd get fixated on a topic for a few months then bounce off and fall into a prolonged depression. When a friend told me that such behaviours were symptomatic of ADHD, I no longer felt defective. Shit made sense. Another tactic is to reorient compulsion towards non-appearance based traits, so that appearance is no longer the foundation of one's self-worth. For example, becoming fixated on making music creates a new avenue for objectification and control that isn't founded on inadequacy, but creativity.
This folds into somatic therapy, which seek to shift one's experience of the body from the visual register to the haptic one. Mindfulness, yoga, and dance can stimulate a joy for one's body and its capacities. A new sense of embodiment both informs one of traumas previously unknown and helps process such trauma into narrative memory so that it is no longer reexperienced, but rather retold. As before, objectification is redirected from estrangement to autonomy.
Lastly, non-violent resistance can help family members or friends reconnect with those suffering from body dysmorphia. This is a framework that understands blame (and dualistic thinking) as the source of interpersonal breakdown, and while its inadequacies become apparent when extrapolated to the political sphere, it's a good framework for identifying and undoing passive-aggressive bullshit, as well as encouraging vulnerability and honesty towards those you care about. As with compassion-focused therapy, non-violent resistance developed out of Buddhism and involves processes of de-escalation and reconciliation. Similar to transformative justice, the first step is a written statement of support towards the person experiencing body dysmorphia—that though friends and family have failed them in the past, they will continue to support them, to learn and grow and love, etc. The next step is an intervention, where grievances are aired and needs are expressed. This is necessarily a social event, so that the cycle of shame and withdrawal is interrupted. As with relational psychotherapy and narrative therapy, blame is avoided, emotions are validated (though not necessarily the actions they drive), and the family system itself is challenged as maladaptive, rather than any one person in it. The last step is reconciliation: in other words, a repair of the social through transformation.
This is unfortunately where my notes end, but hopefully they're helpful, nonetheless :)
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