The Journey of a Psychotherapist Assisted by a Client Affected by Body Dysmorphic Disorder
It was difficult for me to understand Sarah’s level of suffering when she initially came to see me. Sarah, a sixteen-year-old who exuded confidence and brilliance, appeared to have it all: close friends, supportive family, and good grades. Beneath the surface, though, was a struggle so deep and excruciating that it almost brought her to her knees.
Body dysmorphic disorder (BDD) is characterised by a severe and persistent obsession with perceived defects in physical appearance, and it absorbed Sarah. The way Sarah’s nose looked was the “flaw” she could not stop thinking about. She was completely convinced that her glaring flaw made her ugly and unlovable since it was too huge, too bulbous, and too projecting.
Some of the most devastating sessions I’ve ever had were our first few. Sarah was so full of herself that she was crying all the time. She described in graphic detail how she would spend hours every day examining her nose in the glaring light, dissecting it at every turn. She felt disgusted and afraid of ordinary things like eating in public or having her picture taken.
She told me, “I’m a monster,” her eyes overflowing with sorrow. “Everyone must think I’m so hideous and be repulsed by me.”
According to conventional therapeutic understanding, you should maintain objectivity and avoid being overly involved in your client’s emotional journey. However, my heart ached when I heard those words said by someone so young and energetic. I knew I had to find a way to make Sarah realise how gorgeous she was, even from where I was sitting.
Our early work focused heavily on psychoeducation about BDD – because as distressing as her symptoms were, knowledge is power. Sarah learned that BDD is a pernicious disorder rooted in distorted brain circuitry and perceptual distortions, not reality. No amount of cosmetic procedures could ever satisfy the BDD mind, I explained, because its self-loathing voice would just find a new imaginary “flaw” to fixate on.
We also discussed the vicious cycle many with BDD find themselves trapped in – the more you inspect, scrutinize, and ruminate on your appearance, the more distorted your self-perception becomes. Avoiding mirrors and putting effort into hygiene was like dousing gasoline on that fire.
Then came the heavy-lifting: restructuring Sarah’s negative core beliefs about herself through cognitive behavioral therapy (CBT). Over many sessions, we identified, recorded, and challenged the irrational thoughts that kept her BDD flare-ups raging.
“My nose is hideous and that’s just reality.” “If I look like this, I can never be loved or happy.”
“I’m repulsive and everyone sees it too.”
Using Socratic questioning and other CBT techniques, we slowly shed light on the thinking distortions underpinning these bleak self-appraisals. Black-and-white thinking. Overgeneralizing. Catastrophizing. Negative filtering. The greatest battle, though, was waging war on the scorching self-criticism and all-or-nothing perfectionistic standards that demanded utter flawlessness.
With time and practice, Sarah learned to rein in these irrational thoughts before painful rumination and rituals could take over. Crucially, she also worked on more self-compassionate and realistic self-talk:
“Yes, my nose is a little bigger than some, but that’s just one small part of me that doesn’t define my whole self-worth.”
“No one is scrutinizing my appearance as critically as I am. Most people don’t even notice.”
“I am so much more than my looks. I have great qualities that matter so much more.”
Alongside CBT was a heavy emphasis on behavioral experiments to overcome Sarah’s compulsive mirror rituals, arduous grooming habits, and avoidance of everyday situations. We created exposure hierarchies, systematically working her way up from seemingly minor challenges (turning off harsh overhead lighting) to more difficult ones (eating at a restaurant, having her photo taken).
Each small victory chipped away at the distorted BDD beliefs that had kept her trapped. Enlisting her parents’ support was crucial too – they learned to dole out praise and encouragement not about appearance, but about the true beauty of Sarah’s character strengths, values, and inner qualities that shone so bright.
There were many tough days, of course – deeply entrenched patterns are hard to break, and Sarah would get mired in setbacks and bad BDD cycles that tested her resilience. But she never gave up, buoyed by a fierce determination to overcome her demons and live a life no longer shackled by distorted self-perception.
The proudest moment came about a year into our work together, when Sarah bounded into my office one day, beaming. She had tried on various tops for an upcoming event, gleefully showing me photos…and not a single one focused miserably on her nose.
“You know what, Lauren?” she said, eyes sparkling. “I actually felt beautiful for one of the first times ever. And you know what else? My nose looked totally fine! Just…normal. A normal part of my face that I don’t even really notice anymore.”
I’ve had the privilege of witnessing many such revelatory moments in my career. But few have filled me with as much humble awe and sheer joy as watching Sarah’s light emerge from the shadows of BDD that day.
Her recovery was never about making her perceived “flaws” disappear, nor about attaining some arbitrary level of beauty as defined by our culture’s brutal and narrow standards. It was about adjusting the crooked kaleidoscope through which she’d viewed herself for so long – allowing her to see just how lovely, worthy and so much more than her appearance she truly is.
That’s the battle for all of us who work in this field – to shine light into the darkest of self-perception prisons and help those trapped inside break free. With Sarah and others like her, I’m honored to play a small role in that quest for self-acceptance and self-love.
Because in a world that constantly bombards us with demands for perfection and ridiculous beauty standards, making peace with our bodies and being comfortable in our own skin may be one of life’s greatest psychological revolutions.