Cognitive restructuring is designed to correct irrational, self-depreciating, or maladaptive cognitions and beliefs. Clients are taught to identify dysfunctional BDD thoughts and to record alternative thoughts, evidence, and rational responses in their diaries. Veale (2002) suggests that cognitive restructuring is most helpful when working with beliefs about being defective and the role that appearance plays in identity rather than attempting to restructure beliefs like "I am excessively hairy." Rosen et al. (1995) state that some body dissatisfaction is normative and may be challenging to eliminate completely, even with individuals not exhibiting BDD concerns.
Clients may discount or distort information not consistent with their BDD-related belief systems and referential thinking can play a significant role in the clinical picture (Castle & Phillips, 2002). Clients often disregard positive feedback about their appearance and magnify neutral or negative comments. Therapists can encourage clients to record positive, negative, and neutral comments (both solicited and unsolicited) made about their general physical appearance and their particular BDD preoccupation. Behavioral experiments can also be helpful in testing assumptions about appearance and identity. Therapists and clients can collabo-ratively design experiments such as soliciting feedback from cosmetic staff in department stores about the client's long crooked nose or asking close family members about their most engaging personality and physical traits.
An important aspect of targeting appraisals and personal meaning is helping the client construct an alternative model or story for consideration. Veale (2002) suggests the two models include the client's standard assumption, which typically involves being ugly or defective, with the alternative story, which suggests that excessive preoccupation with appearance makes that fixation the most identifiable aspect of self. The models are described as "What you see is what you get" versus "What you see is what you have constructed." This alternate model is most helpful when presented in earlier sessions so clients are able to evaluate both models throughout the course of treatment.
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