Working with Clients Who Cannot Bear to Be Seen
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Nicole Schnackenberg
As therapists, we are used to working with a degree of ambivalence about being ‘seen’. But what about those clients, including individuals with body dysmorphic disorder, for whom the experience of being looked at can feel unbearable? How might we work in face-to-face therapy when our own gaze causes intense anguish? Psychotherapist Dr Nicole Schnackenberg, a specialist in BDD, discusses helpful conceptualisations, adjustments and meeting points when we’re in the room with body-focused shame.
A central aspect of any psychotherapy is making a relational connection with our client. A profound barrier, then, can present itself if being seen by the therapist is affronting and painful; unbearable even.
This is particularly evident in the context of body dysmorphic disorder (BDD). BDD is characterised by a distressing preoccupation with a perceived defect or flaw in the physical appearance that, to the outside eye, is either not visible or viewed as part of normal human variation. BDD can overlap with eating disorders, although the overall focus of distress in BDD is a specific body part or parts rather than the overall weight and shape of the body. BDD affects around two per cent of the adult population and has one of the highest suicide rates of any mental health diagnosis.
Shame and the ‘incorporated gaze’
Clients experiencing BDD feel intense shame when looked at by others, assuming the Other feels the same repulsion and disgust for their perceived appearance defect as they do. Psychiatrist and philosopher Thomas Fuchs postures that shame is immediately related to another’s gaze. Shame is the ‘incorporated gaze of the other’ which resides in the body as an implicit memory, re-surfacing each time the person is seen.
Emerging alongside this incorporated gaze is the sense that the person no longer is the lived body; rather, the person has the corporealised (objectified) body, and therefore the ability (and perhaps responsibility) to manipulate the body’s appearance at will – in part to amend the gaze and perception of the Other. In the therapeutic space this Other is the therapist; is ourselves.
Yet, the fear of being seen in BDD is not the whole story. Simultaneously, the person typically both feels, and yearns not to be, invisible to others. They may feel intensely lonely, inconsequential and unseen within their families and communities. A painful tension between the ‘attach’ and ‘defend’ drives thereby ensues as they attempt to protect themselves from the very people from whom they yearn for love and regard. What we often find in BDD is that the false self, which has been built up around the client’s appearance, is defending them from the fear of rejection of their authentic, true self.
Adjustments to the therapeutic frame
When beginning therapy with clients who cannot bear to be seen, we often need to consider and offer numerous sensitive and creative adjustments. Might therapy be better online initially, perhaps with the client’s camera off and the self-view hidden?
Or, if therapy is taking place in-person, can reasonable adjustments be offered such as an explicit choice about where in the room they would prefer to sit? Clients may prefer to sit as far as possible from the light source(s) or angled towards the corner. They might appreciate having options about lighting (for instance dimmed lights, blinds pulled down or partially down etc.). And they may benefit from camouflage being both permitted and unquestioned, especially in the early stages (for example wearing sunglasses, a scarf pulled up over the face.)
As trust builds and the therapeutic relationship develops, these safety behaviours within the therapeutic space can be reduced or even abandoned entirely. Oscillation is not uncommon, such as a client abandoning their sunglasses during one session, then wearing them the next.
The therapeutic gaze and body dysmorphic disorder
People experiencing BDD often believe what they need in order to feel better is a cosmetic surgeon, dentist or dermatologist: not a therapist like ourselves. A helpful starting point, therefore, tends to be highlighting where our conceptualisation of the ‘problem’ is the same as our client’s: namely, our shared understanding of the distress they are experiencing.
We can then offer the opportunity to explore this distress and, for a set period of time, treat the ‘issue’ as though it was emotional, not physical, in nature. In this way, the distress becomes our joining, starting and guiding point. An element of this is acknowledging the client’s anguish and shame related to being seen both by ourselves and by others.
Therapeutic tools such as themed genograms can be helpful in exploring family narratives around appearance and even particular body parts in both eating disorders and BDD, as can a consideration of wider societal and cultural aspects and influences from infancy.
When our client is supported in thickening the narrative of who they are, including from where and why their appearance-focused distress emerged, they may gradually and increasingly appreciate that our gaze captures so much more than their physical body and it’s appearance. Through this process, it is possible for our gaze, in the perception of the client, to move from appraising and threatening, to non-judgemental and healing.