Problems associated with people’s sense of their own body have increased over recent years and discussions about body image are much more commonly found in the media, alongside those within health and social care. Orbach (2009: 1) suggests that ‘millions struggle on a daily basis against troubled and shaming feelings about the way their bodies appear’. Societal obsession with the perfect body, which includes being beautiful, fit, and slim and remaining youthful; all exert unrealistic pressures on individuals. The images of perfection are everywhere and our bodies are being shaped by forces beyond our control (Orbach 2009). It is not hard to see therefore why society is beginning to acknowledge this as a growing problem.

Over recent years, an increasing amount of literature has emerged, with a number of authors attempting to define body image and develop models relating to practice. Grogan (1999) defined body image as a person’s perceptions, thoughts and feelings about his or her body, which incorporates appearance, body size, shape and attractiveness. Concern about our bodies is normal and allows us to have healthy body awareness. However, excessive bodily concern can lead on to an abnormal focus and can result in bodily obsession or body dysmorphic disorder (Webster’s Dictionary 2008).

A broader view of body image would include more than just the issues relating to appearance but would involve the psychological perception by the individual of their body as being intact, whole and properly functioning. There are many life-threatening and life-limiting illnesses which can cause body image changes, or which impact on how the body functions; these include strokes, multiple sclerosis, rheumatoid arthritis, diabetes and cancer, to name but a few. In addition, the result of life-changing events such as accidents, surgery including amputations and colostomies, leave many people with body image issues. Some of these changes are temporary, while many remain permanent and require the person to adjust to them.

Disfigurement is a particularly difficult body image problem relating to more than just the visual effect of the disfigurement, but linking with the patient’s thoughts and feelings about how it was acquired. Barraclough (1999) reminds us that people cope differently with disfigurement and suggests that some people can be very self-conscious to changes that are not immediately obvious to others. It is important therefore, to assess the patient’s perception of the problem, while suspending our own judgement. One way of doing this is to adopt an approach developed by Berne’s (1972) and ‘think Martian’. When asking the person to describe how they see the problem, we suspend our personal knowledge base and judgement, in an effort to see it through their eyes. This technique is very powerful because, in addition to being empathetic, the therapist also enters into the patient’s ‘frame of reference’ by listening to the language and metaphors they use to describe themselves.

Body image is closely aligned with a person’s sexuality and as such, the authors recommend a broader working definition in order that all aspects of the patient’s persona are acknowledged. White (2006) takes a holistic view in relation to this area of practice suggesting that:

Sexuality embraces the associated concepts of sexual identity, sexual expression or behaviour and intimacy. It is also closely allied with concepts such as body image or self concept, gender identity, gender roles and relationships

White (2006: 676)

Freud (1936) also recommended a similarly broad approach, reminding therapists that sex is something we do but sexuality is something we are and as such incorporates many facets of the individual. It is important therefore, that when assessing patients, prior to offering hypnotherapy techniques, we need to ascertain how their body image concerns relate to the broader view they have of themselves, and whether this affects their roles and relationships with others.

ASSESSMENT MODELS

Assessment of body image and sexual concerns is dependent on the therapist’s attitude, knowledge base and skills in eliciting the patient’s perception of their problems. Three models which provide a framework to assist this process will be considered.

DIRECT/NEGOTIATION MODEL

The DIRECT/Negotiation Model (Box 9.1) utilizes a staged approach to assessing body image and sexual concerns which allows the therapist and patient to proceed at a mutually agreed level. It is a 6-stage approach which is particularly useful when negotiating with the patient as to whether they wish to discuss and work with particularly sensitive areas. Negotiation is used to elicit what the patient is comfortable working with and is used throughout the assessment, enabling the therapist to proceed at the patient’s pace. This can relate to either the depth of communication they are comfortable with, or when negotiating which hypnotherapy approaches they are happy to engage in. (For further explanation of this model, see Chapter 5, and a full version, which also includes Annon’s (1976) P.LI.SS.IT (1976) Assessment Model, can be found at: www://learnzone.macmillan.org.uk.)

BODY IMAGE MODEL (PRICE)

Price (1990) developed a 3-stage model which enables the therapist or healthcare professional (HCP) to identify and explore different aspects of a patient’s body image:

1. The first aspect is ‘body reality’. This is the ‘warts and all’ of our body image which we may or may not choose to share with others. Under normal circumstances, the ‘body reality’ may not be problematic. However, when people are unable to keep these aspects hidden, either due to illness or lack of privacy, problems may begin to emerge. Our body reality changes throughout our lives, with a number of changes occurring at times of transition, such as puberty and menopause. Most people adjust to these changes without any support. However, for some, this can be the time when body image concerns begin to develop. The changes and challenges which occur throughout puberty can be the catalyst for problems such as anorexia and bulimia. Also the losses which occur around and following the menopause, may for some people be more difficult to adjust to.

2. The second aspect of the model is the ‘body ideal’. This is the picture in our heads of how we would like to be and may well be unachievable for most people. The media presents the ‘ideal look’ encouraging us to aim for perfection by promoting youthfulness and vitality. Most people, even the young and beautiful struggle with this ideal and those with body image changes due to illness or injury are often moving further away from the original ideal image they had of themselves. Orbach (2009) questions why bodily contentment is so hard to find and it would appear that the answer might lie in the constant striving for the ‘body ideal’.

3. The third aspect of the model is ‘body presentation’. This is how we present ourselves to the world and links with the term ‘being presentable’. Even this can be greatly compromised when people are ill or taking medication whose side-effects impact on their body image. In these situations, what is often presented to the world, is their body reality (and perhaps a new even less positive body reality), which for some patients is very distressing. Examples might include: hair loss or weight gain from steroids, or where a disfigurement is impossible to hide.

BODY IMAGE MODEL (CASH & PRUZINSKY)

Cash & Pruzinsky (2002) have developed a useful framework for assessing body image concerns. Their book offers a variety of tools which patients can use individually or can be used to form part of their therapy. A body image diary is used as a way of reflecting on their body image concerns. Patients are encouraged to notice:

• Activators – triggering events/situations which raise body image concerns

• Beliefs – what thoughts and interpretations they deduct from this

• Consequences – the emotional tide occurring as a result of the body image concerns being activated.

They are asked to name and record the types of emotions they feel, their intensity (scoring them from 1–10), their duration and any effects they have on their behaviour. This may include avoidance behaviour, which is common in this group. This information can then be used to form the basis of any work undertaken using hypnotherapy.

Applying hypnotherapy

When looking at using hypnotherapy in this area of practice, the following examples may be of use to practitioners.

The American Society for Clinical Hypnosis (2009) suggests three main ways of practicing hypnotherapy:

1. The first is to encourage the use of imagination. Patients are asked to imagine what they see and the therapist may go on to work in a way that helps them to change a negative image. This will be further explored when looking at Cunningham’s (2000) model below.

2. The second way is to present ideas or suggestions to the patient, which in the case of body image will help them to use positive suggestions in order to reframe their perception of the problem.

3. The third way is to use hypnotherapy for unconscious exploration and is used to explore motivation or links with past events. Hypnosis avoids the critical censor of the conscious mind, allowing the interface between the conscious and unconscious, which results in the client having the information they need to make the changes.

IMAGERY

Imagery is an important aspect of working with body image issues. Two modes of imagery, which are useful in facilitating this process, are: ‘diagnostic’ and ‘therapeutic’ (Cunningham 2000).

Diagnostic imagery

Diagnostic imagery can be used just to elicit information, or in addition can form the basis from which the therapist works using hypnotherapy techniques. During the imagery, ideas/information from the unconscious become available, which is not always accessible from the rational mind. The wealth of information that the unconscious holds, allows patients to gain new information in order to bring about healing. The therapist is the privileged facilitator of this.

Therapeutic imagery

Therapeutic imagery entails working in a positive way with the images the patient presents, based on the principle that images affect body function. The therapist encourages the patient to imagine beneficial changes in the images they see. The patient gets in touch with both their conscious and unconscious, to consult with their ‘Inner Healer’ in the imagination, to bring about healing from within (Cunningham 2000). From practical experience, patients work well using this approach. They are usually very inventive and can fill up empty spaces with ‘magic healing fluid’, making it the colour and consistency which is just right for them. They can change parts of the body which look dark and diseased by flushing out all the dark colours and replacing them with bright healing colours. Often the healing comes about in the patient’s unconscious through seeing themselves whole again; even though the physical reality may be different.

CLEAN LANGUAGE MODEL

Finally, another useful framework worth consideration is that developed by Grove and Panzer (1991) to resolve traumatic memories. The basis of the model is the use of what they refer to as clean language (using the patient’s words). They assert that this ensures that the patient’s meaning and resonance remains wholly intact, and is uncontaminated by the therapist’s words. Working in this way opens the door to change through developing a much more naturalistic trance which avoids evoking resistance. The therapy begins by inviting the patient to tell their narrative, paying attention to the language they use. This is done by examining the auditory, visual and kinaesthetic channels used, in addition to noting how they use language in order to describe their experiences and inner realities.

The model suggests that a patient may express their internal reality in one of four languages. These are expressed as: memories, symbols, metaphors and semantics, and the therapist’s role is to discover which of these appears to be predominant.