John Stafford
Brandman University
Table of Contents
Vignette
Seth is a 50-year-old African American male who tells you about his counseling history intake paperwork that he identifies as bisexual. He reports these feelings about questioning his sexuality had begun about a year ago when he started going out to gay bars and nightclubs. Seth tells you that he is deeply insecure to start any relationships and that he feels very lonely. Seth indicates he is extremely self-conscious and it is hard for him to attend social events because he is always comparing himself to his thinner friends. Seth reveals he does not eat a balanced diet, hardly exercises, and his doctor told him he is in the “morbidly obese” category, which made him “never want to go to a doctor out of my house ever again.”
Keywords: Social Anxiety, Anxiety, Depression, LGBTQ, Eating Disorders, Obesity, Interpersonal Relationships. Acceptance and Commitment Therapy
How Body Image Impacts Interpersonal Relationships
Social anxiety is a standard issue in any culture and social structure. However, additional pressures related to personal perception, sexuality, social constructs, body image, and cultural acceptance may add other stresses that compound existing internal deficits. For example, an individual struggling with both body image and sexuality is more likely to experience heightened anxiety levels when he or she is attempting to assimilate into a specific environment.
Seth is experiencing aspects of internal acceptance of his sexuality that include confusion, cultural expectations, ageism, and self-consciousness associated with his current physical state. These issues make every-day life complicated and frustrating for Seth as he attempts to navigate his expectations of interpersonal relationships, and overall satisfaction with his everyday life.
Cultural Issues
Seth comes from an African American culture. Understanding the cultural diversity of working with different cultures is essential as African Americans approach therapy from a different perspective than the Anglo-Saxon culture. Seth will most likely be more responsive to direct communication that offers more direction than other vague forms of treatment that only guide the client to find his or her answers. Family concerns are also significant in the African American culture as they view family bonds as more important than societal relationships.
Sexuality Issues
Seth’s sexual orientation is an issue that requires attention. The LGBTQ community can be very superficial, and body shaming is common amongst gay men. Bisexuality as another issue that can be met with mixed opinions in the gay community because many gay men view bisexual males as being less desirable. Furthermore, safe-sex practices add additional complications for bisexual men because modern preventative treatments like PreP have changed how gay men approach sexual relationships.
Suggested Referrals
Several aspects come into play when considering referrals. Seth has an admitted weight concern that he wants to address, along with concerns he has surrounding his sexuality. Seth has stated that he had a bad experience with his current doctor when the issue of weight, so I would suggest referring him to a weight loss specialist that can help him formulate a comprehensive dietary program. Additionally, I would recommend that Seth attend group therapy at a local LGBT center for men dealing with bisexuality. Seth would gain tremendous insight and increased comfort levels being part of a group of other men experiencing the same emotions and feelings he is currently experiencing.
DSM Criteria
Social anxiety disorder or social phobia is a disorder that affects an individual in social settings. Symptoms can manifest as discomfort in social interactions, concerns about being embarrassed in public spaces, or of being judged by others (American Psychiatry Association, 2013). Individuals experiencing social anxiety disorder are likely to display heightened levels of anxiety and fear associated with autonomic arousal that includes apnea, diaphoreses, nausea, tachycardia, and tremors and can range in discomfort, including minor symptoms to disabling fear (National Institute of Health, n.d.; Anxiety and Depression Society of America, n.d.).
Symptoms
The DSM-V lists ten different diagnostic criteria for social anxiety disorder that include; 1. Fear or anxiety specific to social settings,
2. Fear of experiencing social rejection due to displaying anxiety,
3. Provoked distress during social interaction,
4. Avoidance, or painfully and reluctant social interaction,
5. Fear of disproportionate anxiety in comparison to the situation
6. Fear or anxiety associated with social situations that persist for six-months of longer,
7. Personal distress and impairment of functioning in one or more domains, including interpersonal and occupational functioning,
8. The symptoms not associated with adverse medication effects, substance abuse, or a medical disorder,
9. The signs not related to another mental disorder,
2. Fear of experiencing social rejection due to displaying anxiety,
3. Provoked distress during social interaction,
4. Avoidance, or painfully and reluctant social interaction,
5. Fear of disproportionate anxiety in comparison to the situation
6. Fear or anxiety associated with social situations that persist for six-months of longer,
7. Personal distress and impairment of functioning in one or more domains, including interpersonal and occupational functioning,
8. The symptoms not associated with adverse medication effects, substance abuse, or a medical disorder,
9. The signs not related to another mental disorder,
10. Another medical condition results in excessive self-consciousness
(American Psychiatric Association, 2013).
Comorbidity Concerns
Comorbidity occurs when social anxiety disorder combined with other anxiety disorders, depression, and substance abuse (American Psychiatry Association, 2013). A primary comorbidity concern is a depression brought on by isolation and inability to make social contracts, which leads to extreme loneliness (National Institute of Mental health, n.d.; American Psychiatric Association, 2013.; Anxiety and Depression Society of America, n.d.). Seth has indicated that he does experience loneliness, which raises concern for depression as a secondary diagnosis.
Justification of Diagnosis
Based on the information from Seth’s intake, several of the criteria for social anxiety disorder are applicable. Seth indicated that his insecurities associated with self-image make is uncomfortable and awkward for him to engage in social settings. It would suggest that he is excessively self-conscious about his weight and that he is isolating himself from participating in social activities to avoid being judged by others and rejected for both his physical appearance and his anxiety or discomfort when he is in a social setting. Additionally, because Seth experiences loneliness resulting from an inability or fear of personal relationships, the concern for depression is a factor not to be overlooked and reflect in the diagnosis.
Therapeutic Methods
The DSM-V indicates that cognitive behavioral therapy [CBT] is the most common modality of treatment for social anxiety disorder. It is commonly performed using exposure therapy in which the client gradually exposes himself to anxiety-provoking situations, and then associating the distressing stimulus with a relaxation or indifference response also referred to as systemic desensitization (National Institute of Mental Health, 2014). However, due to additional circumstances like body image and sexual identity issues Seth is experiencing, I believe that his social anxiety symptoms coincide with these issues and that addressing his social anxiety alone will not alleviate the underlying concerns. As a result, I think that Acceptance and Commitment Therapy [ACT] is a viable option of treatment for Seth. Because Seth has multiple issues that require attention, I believe that adding a CBT component to his treatment plan would provide additional benefit. CBT has demonstrated consistent success in helping clients experiencing weight loss problems. Using the CBT/ACT combination to focus on his weight loss in conjunction with a referral to a weight loss specialist, I believe Seth will be successful in understanding, setting, and meeting his goals.
Acceptance and Commitment Therapy
The goal of ACT is to help the client accept issues associated with his or her presenting problems and make a commitment to living life by embracing those issues as part of oneself (Hayes, & Lillis, 2012). A critical aspect in ACT is enlisting the client to be an active participant in the therapeutic process, focus on the present, consciousness, and values that he or she wants to live. The therapist is required to assist the client in becoming more aware of themselves as a “whole person” by getting in touch with their feelings, thoughts, and live by their values (Hayes, & Lillis, 2012).
Seth’s presenting problems are related to his social anxiety, but the underlying issues of his body image are emphasizing both his sexual identity issues and causing his social awkwardness. Treating Seth’s social tension as the primary issue will effectively only be putting a bandaid on his mental well-being because the underlying causation[s] is not alleviated. While treating the social anxiety may help Seth in some social settings in the short term, his body image issues will continue to plague his ability to function in social environments and prohibit functional interpersonal relationships.
Acceptance and Defusion
The goal is to work with Seth to accept his feeling and thoughts without acting on them. The process includes walking through Seth’s feelings and emotions when he is in social settings and recognizing that obsessing or worrying about them is what makes him feel stuck or suffocated. By letting the thoughts and feelings happen without an impulsive reaction, Seth will be able to begin taking more control over how he feels, thinks, and reacts to his anxiety. Using techniques that help Seth observe the physical feelings associated with his fear, he will be able to identify how he interprets the experience and begin to replace the negative thoughts with realistic ones, ultimately providing him a new outlook on how he sees and reacts to the maladaptive expressions of his anxiety.
Values-Based Action
Seth struggles with social and interpersonal interactions because he believes he is grossly obese. Weight issues are a frequent contributor to social dysfunction because individuals feel that they get judged on their appearance. It would, in many cases, be a correct assumption. If Seth wants to be healthy and remove the stressors associated with his weight issues, he needs to act on his values of living a happy and healthy life with improved social interactions. This phase includes pulling from his values to help him recognize the need for a proper diet and exercise regimen that start producing those results.
General Treatment Overview
The treatment plan for Seth should start by helping him understand and accept the thoughts associated with his social anxiety to minimize their impact when he is in a social setting. Additionally, assisting Seth to get in touch with his values of how he wants his life experiences to will help him understand that much of his anxiety and interpersonal interactions are a result of his weight and body image issues.
By focusing on his values and making cognitive changes, Seth can start working on a plan to work on his weight, hence reducing his social anxiety problems. Additionally, by using defusion and mindfulness techniques to help him understand and stop avoiding his thoughts and feelings when he is in a social setting will have an additional positive impact on his self-esteem as friends and people he interacts within social environments start noticing changes in his physical appearance.
Cognitive Behavioral Therapy
Cognitive Behavioral Therapy [CBT] is widely used to treat a variety of different mental health problems. In the area of weight loss, CBT is proven the most successful therapy modality for treating patients suffering from binge eating disorders. Most studies show that dieting alone does not provide successful outcomes in weight loss. A comprehensive program of dieting, exercise, and a cognitive component that retrains the client’s thoughts and processes of eating is a well-rounded program geared for success (Greenberg, 2011; Leigh, 2004). Considering the biological factors that impact weight loss, no one-stop solution guarantees success. Cognitive Behavioral Therapy offers a variety of techniques like mindfulness-based eating awareness, self-monitoring, and cognitive-based coping skills for weight loss (Greenberg, 2011).
The second consideration for CBT is Seth’s social anxiety. Cognitive behavioral therapy, recognized as one of the prominent treatments for social anxiety disorder, provides the client with specific tools and goals for successful treatment. By helping the client modify maladaptive thoughts and emotions, CBT teaches the client to be more assertive, cope with guilt, anger, and embarrassment, and correct misconceptions he or she has about their abilities and self-worth (Cuncic, 2018).
Cognitive Restructuring
The benefit of cognitive restructuring applies to both dietary issues and social anxiety. The process teaches the client to identify upsetting ideas, mental image, and negative self-talk that induces both eating disorders and social fears by comparing them to real-life evidence and experiences. By doing so, the client can begin reformulating how he or she views things and adapt maladaptive thoughts to constructive thoughts and attitudes toward similar experiences. However, this is only the beginning of the cognitive modification process.
Mindfulness
Learning mindfulness techniques will provide a considerable advantage in addressing both social anxiety and weight loss. Mindfulness gives the client the needed tools to identify and replace maladaptive thoughts and feelings while refocusing on the moment and desired goals. In social situations, mindfulness techniques help the individual return to or stay in the moment allowing for more comfortable interactions with others. For weight loss, learning mindfulness techniques enable the client to remain focused on their eating habits, the desired changes, and stay focused on their weight loss program.
General Treatment Overview
Cognitive behavioral therapy provides a solid treatment plan for social anxiety and weight loss issues. Seth would benefit from this therapeutic model because it will help him learn various skills needed to overcome the blockers that affect his presenting problems. Using a combination of mindfulness exercises and cognitive restructuring, Seth will be able to identify, control and modify the maladaptive thoughts, emotions, and behaviors associated with his weight and social issues.
The cognitive restructuring includes the identification of maladaptive thoughts and feelings resulting in undesired behaviors and outcomes. Learning to identify these thoughts and replacing them with positive thoughts will result in enhanced interactions in social environments and address underlying issues that affect dietary difficulties. Mindfulness techniques include meditation and other exercises that aid the client in tuning into his or her body cues and emotional processes. Using mindfulness exercises will help Seth stay focused and relaxed during stressful social encounters and reduce emotional eating issues.
Treatment Plan
A treatment plan should represent a comprehensive program that includes a set of goals and treatment modalities that both the therapist and client agreed to. It should consist of any suggested referrals to outside providers who provide services that will benefit the client. One of the critical aspects of the treatment plan are the short and long-term goals easily measured against the presenting problems and client satisfaction. Finally, termination of therapy should involve discussion with the client to determine his or her perspective on the effectiveness of treatment, how the termination process works, and to make sure the client understands that the therapist is available for any needed follow-up sessions, should the client need.
Short-Term Goals
Any therapy plan requires realistic short-term goals the client wants to meet. Seth wants to address his social anxiety and weight loss. Although weight loss is a long-term process, there are short-term goals needed to begin the path. Because Seth’s weight is also underlying causation of his social anxiety, the first step in the treatment process is to help Seth get into a comprehensive weight loss program that includes referral to a weight loss specialist, an exercise program, and therapy sessions. Secondarily, beginning work on Seth’s social anxiety will help in multiple ways. Becoming more comfortable in social settings will help Seth experience less stress and reduce the potential for stress-induced eating habits.
Long-Term Goals
Meeting short-term goals provides a sense of accomplishment and satisfaction for the client. However, these can quickly become detrimental if the client is not focused on long-term goals, even if they are the same or similar to short-term. Seth has a long road ahead of him with his weight loss issues. Typical weight loss programs have setbacks that can be discouraging to the client. Maintaining a therapeutic direction that focuses on the long-term outcome will help decrease the disappointment associated with any delays, and help Seth retain focus. Because Seth’s weight affects his social anxiety, there will need to be a long-term goal of continuing work on his social issues. Another component for Seth is joining a group for bisexual men. Over time, Seth will learn to become more comfortable with his sexuality, and as his other issues begin to improve, Seth will become more comfortable engaging in personal relationships.
Termination
As the Seth progresses through the phases of treatment, he should be able to begin social interactions with less stress as he works on the primary issue contributing to his social and interpersonal interaction issues. His ability to defuse from the dysfunctional thoughts and emotions associated with anxiety and continuing work on his body image issues will have multiple positive effects over the long-term. Understanding upfront that his weight issues do not align with his values and not an unresolvable situation will also produce a positive social impact as he interacts with people and notices physical improvements.
Conclusion
Working with patients is not a one-step process with natural solutions. Each client has different presenting problems compounded with multiple symptoms and underlying causes. A client that presents with various issues like weight loss, social anxiety, and sexual identity problems presents a challenge for the therapist when it comes to which therapeutic techniques are best suited to treat the client. What a single therapeutic method can accomplish may not be the answer for that particular client. Blending techniques can seem convoluted but may produce a much more desired process and results. Acceptance and Commitment Therapy and Cognitive Behavioral Therapy are two very different theories that, if used correctly, blend to provide the client with a well-rounded therapeutic process that provides tremendous benefit to the client.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Association.
Anxiety and Depression Association of America. (n.d.). Social Anxiety Disorder. Retrieved from http://www.adaa.org/understanding-anxiety/social-anxiety-disorder
Cuncic, A. (2018). How Cognitive-Behavioral Therapy Can Treat Social Anxiety Disorder. Retrieved from https://www.verywellmind.com/how-is-cbt-used-to-treat-sad-3024945
Greenberg, M. (2011). To Lose the Weight, Change How You Relate (to Food). Retrieved from https://www.psychologytoday.com/us/blog/the-mindful-self-express/201102/lose-the-weight-change-how-you-relate-food
Hayes, S. C., & Lillis, J. (2012). Acceptance and commitment therapy. Washington, DC: American Psychological Association.
National Institute of Mental Health. (2014). Anxiety Disorders. Retrieved from http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml
National Institute of Mental Health. (2016). Anxiety Disorders. Retrieved from http://www.nimh.nih.gov/health/topics/social-phobia-social-anxiety-disorder/index.shtml
Rich, L. E. (2004). Bringing More Effective Tools to the Weight-Loss Table. Monitor on Psychology,35(1). Retrieved from http://www.apa.org/monitor/jan04/bringing.aspx
