Book Review: Conceptualisation, Research and Treatment

Not only is the body that part of us that is immediately observable to others, it is also connected to a complexity of self-conscious experiences. It has been noted that while we may think of ourselves as individual minds or personalities, our existence can only take place in an embodied self.

(Gilbert & Miles, 2002 p.27)

The body is the site in which we act. When that body ceases to function as we think it should, we often seek ameliorative action, either self-guided or through medicine. What happens, though, when the body cannot be changed? What occurs when our body technology fails or we own strategems are insufficient to produce desired change? Should we seek to strategize instead on our cognitions and interpretations, to relegate the body to a supporting player, a casting worthy of minimal attention only? In cases where individual body perceptions are markedly at variance with mass perception, this would indeed seem a sane option. Anorexia nervosa would seem in its later stages to be just one such candidate, but what happens when, from the very start, the mass of public opinion recognises difference and values it on a less deserving scale?

These two books Visibly Different and Body Shame are in their different ways explorations of such issues. Although contemporary Western society is often held up as being fixated on external appearances this is only partially true. The ideal representation in our society involves not only a merging of the external appearance with the internal world but also, increasingly, with the environment. The fact that many people are fixated on the appearance of their houses and immediate environment suggests both displacement – an escape from the more difficult task of living with oneself - and an inability to cope with ambiguity, contradiction and divergence. For 'lifestyle balance' and 'planning' read conformity and intolerance of the 'other', the 'alien' in our midst. One does not have to look far to find potential candidates for such categories: asylum seekers; paedophiles; drug addicts; those with severe and dangerous personality disorder and so forth. In many respects we can recognise our own mythic constructs in such terms, while also establishing sane reasons for the exclusion/treatment of such people. It could be argued that such responses are generated by the public towards 'fearful categories' and have a high degree of social legitimacy.

What, though, about those forms of exclusion that are both self and other generated? What happens when an individual recognises not only their difference, but is also acutely aware of how that difference is perceived and acted upon by others.

Visibly Different subtitled 'coping with disfigurement' published in 1997, is the older of the two books reviewed and as the title indicates focuses primarily on the power of the external appearance. In this case, such power is not about any comfortable match between an individual's appearance and societal values, but about mismatch and the effect and management of spoilt identities.

Visibly Different is structured around three themes: (i) the experience of being visibly different' (ii) research and (iii) coping mechanisms. The personal accounts given in the first part of the book make for powerful reading, particularly in those chapters where another account has been sought either from friends or family. What this information allows us to do is to vicariously experience being both the perceived and the perceiver. Where this happens one can begin to experience the complexity of experience. Perceiving oneself as different is largely an internal affair, whereas being perceived as different occurs within a social context. Being visibly different is a factual state of affairs. Sartre (1991, p.351) notes that 'With the appearance of the Other's look I experience the revelation of my being-as-object; that is of my transcendence as transcended.' There may be a mismatch between the extent to which an individual who is visibly different believes this to be their foremost characteristic and those close to them, but bodily difference can never really go unnoticed. Even in those situations where the awareness of visible difference is minimised, the social world can exert a great influence on these perceptions:

The awfulness of it all really struck me when I was about seventeen (so Jane was eighteen), and Jane and I were out shopping. People were staring at Jane, in disgust, the way people stare at someone who's deformed. I was furious, and just couldn't believe or understand it and I was seething with anger, but then I remember looking at Jane and seeing that she hadn't noticed the staring, but also that she really was very spotty. I almost cried then, but instead just glared at everyone that looked at her and then rushed home. I didn't say anything to Jane because I hoped she hadn't noticed, and I didn't want her to know and then get upset. (Jane's younger sister commenting on her sister's severe acne)

(Lansdown et al, 1997, p.63)

Thus, while attenuation may occur through proximity and through a focusing on other senses beyond that of the purely visual, it is clear from accounts such as these that bodily difference is less about presence/absence and more a matter of degree.

The second section of the book on research and assessment works less well than either this first section, or the final section on coping with visible difference. As a resource it is too brief and rather too general in places. The main problem with this section is that essentially this is a book about lived experience and not really about formal research and assessment techniques. The third section of the book is a sound idea and draws out the psychological needs of those with visible disfigurement. Sadly though, none of the chapters really managed to provide a detailed enough sense of the work that can be usefully undertaken therapeutically in these cases. Moreover, given that the second part of the book did examine some of the research literature it would have been instructive to read how particular approaches were derived from the evidence base.

Such criticisms aside this is an interesting book that sparked off a number of thoughts in my own mind about the needs and ongoing difficulties that people with visible disfigurement face. For the existential therapist there is an important balancing act to be struck between what Sartre called possibilities and dead-possibilities (Sartre, 1991, pp.304-305). How do you focus on the needs of clients to explore their sense of self while recognising the enormous and ongoing pressure from others, concerning that very same self. When Kierkegaard states that 'the crowd is everything and nothing' he is reminding us that the existential task that faces the individual cannot be isolated from the wider social context. Autonomy, independence and the creation of personal meaning are not ingots that can be picked up and pocketed, but more like panes of glass, vulnerable to the stones that other people throw. In the Kierkegaardian scheme of things this is not necessarily something to regret. For Kierkegaard the task is to become 'the single individual'; to exist is to stand out, to be differentiated from others. For those with visible disfigurement this is something that is continually done for or to them:

In their attempts to go about their daily lives, people (with disfigurement) are subjected to visual and verbal assaults, and a level of familiarity from strangers... (including) naked stares, startled reactions, 'double takes', whispering, remarks, furtive looks, curiosity, personal questions, advice, manifestations of pity or aversion, laughter, ridicule and outright avoidance

(Macgregor, 1974, p.250)

Yet the Kierkegaardian intent is about more than just differentiation; to become the single individual is to become what one is. Thus, Jansen (1990, p.3) usefully reminds us that 'By means of the category of the single individual, Kierkegaard states his basic premise for the assessment of the quality of human existence. The meaning of human life is not determined collectively; it is determined by each and every human being himself/herself. The prerequisite is self-awareness, and the process whereby life becomes meaningful is a process of personal, subjective appropriation.' To become this single individual one must become engaged in a process of continual striving. The fact that visible difference does often result in social commentary and personal suffering does mean that the pre-requisites of existential exploration are in place. The question is whether we have an existential approach sufficiently mature to deal with the traumas of visible difference.

It may be worth remembering that despite all of Kierkegaard's own analysis of the individual and the crowd, The Corsair affair affected him deeply. The Corsair Affair for readers unfamiliar with the incident, centred around Kierkegaard challenging a weekly scandal sheet called The Corsair to satirize and pillory him in the way they had many other prominent people. The paper took up that challenge with avidity. As Gates (1961, p.102) notes 'The Corsair for the next eight months missed no opportunity to place Kierkegaard in the worst possible light before the Danish public: a selfish, snobbish aristocrat; a half-crazy eccentric; an ugly, ludicrous, misshapen monster.'

Even though this was also an affair largely instigated by Kierkegaard himself 'I exposed myself of my own free will to become a laughing stock' (Dru, 1969, p.163), such autonomy did not protect him from feeling the effects of the paper's satire:

But when, for example, I have sought recreation by driving three or four miles and my body has gradually become somewhat weak, partly by the drive, and partly by the sheer occupation of my spirit, when I get out of the carriage and it happens that I am met by a grinning assembly, there is sure to be some one present who is jolly enough to call me names – it has a very strong effect upon my bodily disposition. Or when I have made a long excursion out along the lonely roads, engrossed with my thoughts, and then suddenly I meet three or four louts out there where I am entirely alone, and these then take to reviling me, then it has a strong effect upon my bodily disposition

(Lowrie, 1962 p.353-354)

Although Kierkegaard was able to process what had happened to him in terms of his overall purpose, the sense of hurt still rings through:

I do not feel any bitterness at the thought of all the scorn that I have suffered, and the treachery that I have endured... I feel quite sure in eternity there will be time and place for jokes, I am certain that the thought of my thin legs and my ridiculed trousers will be the source of thought of my thin legs and my ridicules trousers will be the source of thought of my thin legs and my ridicules trousers will be the source of thought of my thin legs and my ridicules trousers will be the source of thought of my thin legs and my ridicules trousers will be the source of thought of my thin legs and my ridicules trousers will be the source of the greatest amusement to me... What I suffered in that respect I suffered greatest amusement to me... I did a good work humanly speaking, with a disinterested sacrifice...

I have never been a Diogenes, I have never touched the frontiers of cynicism, I am properly and respectably dressed-I am not responsible for a whole country having become a madhouse.

(Kierkegaard, 1939, pp.235-236)

That someone like Kierkegaard can turn this to positive effect is a magnanimous difference between instigating instructive, yet we should not minimise the difference between instigating an attack upon oneself and simply being the victim of such an attack. Psychological acceptance is a far easier task when we can acknowledge our own responsibility for certain outcomes. Visible difference, it would seem, can exert powerful influences both upon others and ultimately upon the conceptions that we hold of ourselves.

It is this internal world that is the primary focus of Body Shame. Body image disturbance is not a new area, either in terms of research or theory and it is important at the outset to highlight why the term 'body shame' has been used by Gilbert and Miles for the title of their edited volume. They note that the 'concept of 'body shame' directs attention to negative experiences of both appearance and functions of the body, which can involve various sensory modalities… the experience of shame can be focused on many characteristics of the self, such as feeling ashamed of emotions; behaviours; perceived personality traits' (p.3).

As an overview of the field this book has to be commended. Like 'Visible Difference' there is a section devoted in this book to 'Body and Disfigurement,' however, there is also a whole section devoted to body shame and psychological disorders, as well as five very useful introductory chapters including two on shame in relation to childhood and shame in relation to the ageing body.

The chapters on disfigurement cover psoriasis, acne, burns, bowel disorders in children and prostate cancer. The chapters on psychological disorders cover blushing, eating disorders, childhood abuse and body dysmorphic disorder. In my own clinical practice working with in-patient addictions I have encountered many of these clients with alcohol and drug addictions issues and have often had to rely on the research papers to guide me towards the most effective treatments. Interestingly, the area of body shame in the context of addictive behaviour has been relatively neglected despite the devastating effect this can have on the individual's body.

Body Shame is very much centred on current research, much of it cognitive behavioural, but this I would argue should not undermine its relevance for existential practitioners. In my own practice the two approaches are often fused together and clients do not seem to experience any contradiction within this. Paul Gilbert in his excellent chapter 'Body Shame: A biopsychosocial conceptualisation and overview, with treatment implications' notes that 'Shame is not only a personal, distressing-affective experience but it penetrates into the subtlest levels of our being' (p.126). It is this recognition of the centrality of the body and our perceptions of it, that make it such an important topic within existential theory. Even where the body is not the central focus of attention for those engaging in therapy, an awareness on the part of the therapist may be rewarding.

The ageing body examined by McKee and Gott in this book remind us that body appearance and body function are not correlates, and that satisfaction with one does not necessarily result in satisfaction with the other. Any such satisfaction is of course an opening in therapeutic terms and arguably for the existential therapist it is dissatisfaction with body appearance that more easily opens up a focus on the role of the individual versus the other. That both Visibly Different and Body Shame are mainly concerned with appearance rather than function increases their relevance and in different ways these are 'existential books' all but in name.

References

Dru, A. (1969). The Journals of Kierkegaard 1834-1854. London: Fontana Books.

Gates, J. A. (1961). The Life and Thought of Kierkegaard for Everyman. London: Hodder and Stoughton.

Jansen, N (1990). The Individual Versus the Public: A key to Kierkegaard's views of the daily press. In Robert L. Perkins (Ed.) The Corsair Affair: International Kierkegaard Commentary Volume 13. Georgia: Mercer University Press.

Kierkegaard, S. (1939). The Journals of Soren Kierkegaard. Ed and Trans. A. Dru. Oxford: Oxford University Press.

Lowrie, W. (1962). Kierkegaard Volume Two. New York: Harper and Brothers.

Macgregor, F. (1974). Transformation and Identity: The face and plastic surgery. New York: Quadrangle.

Sartre, J-P (1991). Being and Nothingness. London: Routledge.

R.G. Hill