In December 2014I had the privilege of attending the Acceptance and Commitment Therapy (ACT) & Contextual and Behavioural Science (CBS) Conference and Workshops in Dublin.

ACT (spoken as a single word not A. C. T.) is part of the third wave in Cognitive and Behavioural therapy. This is the new generation of CBT therapies.

What came out of this for me other than depth of therapy skills, was how to present this to groups of patients so that more patients can benefit from this without compromising the level of the work that I can do on a one to one basis.

In addition to one on one, I will now be offering small group workshops. Working alongside others who have similar difficulties often help patients to see that they are not alone in their suffering. It creates a “we are all in this together” camaraderie which encourages them to help each other too.

One of the strengths of this therapy model is that it is far reaching in that it can be used for people with anxiety, depression, low self-esteem, stress, burnout, chronic pain, preparation for life changing events like retirement, to mention just a few.

In previous years I only offered this on a one to one basis, but this year, I will complete the initial consultations and assessments on a one to one basis and then if the patient is right for group work I will offer that to them.
I will do the teaching in the group personally.
I am hoping that this will make therapy more accessible to clients and more be helped.

I will continue to do one on one therapy too.

Quick chicken and pepper stir fry

Green pepper x 1
Red onion(s) x 2
Red pepper x 1
Quinoa x 200 gram(s) (remember that this is a protein).
Yellow pepper x 1
Skinless chicken breast x 4 fillets
Cashews x 1 gram(s)
Sunflower oil x 1 tbsp
Soy sauce x 2 tspn
1. Cook the Quinoa according to the pack instructions.
2. While the Quinoa is cooking, heat the oil in a large pan or wok, and add the sliced onion and chicken, cooking for 5 min.
3. Add the remaining vegetables and cashew nuts to the pan and stir.
4. Add a little water and a dash of soy sauce to flavour.
5. Continue to stir until vegetables start to soften a little.
6. Drain the cooked quinoa and serve with the stir fry.

SPICY LENTIL SOUP

Ingredients
1 large onion, chopped
2 cloves garlic, crushed
1/2 tsp ground coriander
1/2 tsp ground cumin
l litre (4 cups) vegetable stock
300g 1.5 cups red lentils
1 can chopped tomatoes
fresh corianderand plain low-fat yogurt to serve (optional)

Method

Put the onion, garlic and lentils in a pan. Sprinkle over the ground spices and stir to mix.
Pour over the hot stock, bring to the boil and simmer for 10 minutes.
Add the tomatoes and cook for a further 10-15 minutes, until the lentils have softened.
Blend the soup. If you wish, garnish with a swirl of yogurt and a scattering of fresh chopped corianderleaves on each bowl to serve.

I have been setting up a specialist anxiety clinic. For many years I have been working with patients suffering from a variety of anxiety based disorders and have found at 6 month follow-up irrespective of the type of therapy, something was lacking for some. So, I started to look outside the box and found an extensive amount of research around the reduction of anxiety using exercise.

As a result of the research of people like Oeland AM, Laessoe U, Oleson AV, Munk-Jorgenson P C. Barr Taylor, MD James F. Sallis, PhD RNeedle, PhD, I have integrated exercise (with a personal trainer) with specific type of CBT to form a new type of evidence based therapy for clients suffering from anxiety related illness. This integrated therapy will float under a positive Therapeutic Relationship. I still believe that it is the Therapeutic Relationship that far outweighs any other factors in therapy and it is from there that one needs to integrate whatever therapy will meet the need of the client.

This therapy model works with the client from both body and mind perspectives.  I also feel that the effects of exercise which are similar to the symptoms of anxiety i.e. shortness of breath, elevated heart rate, tightness around the chest, sweating will be reframed into a positive experience with the help of therapy and therefore on an experiential level their angst about feeling anxious will be brought under control a lot faster.

Do the free Anxiety test on my main website under the “Do I need Therapy” tag.

Title: Like Daughter, Like Mother…

TANIA G. BLOM

Private Practice, Bristol, UK

ABSTRACT

This article presents the results of a qualitative study on the psychosocial effects of breast reduction surgery in a set of mother-and-daughter pairs. The overwhelmingly positive effects of the surgery on the daughters encourage the mothers to address their own body image, with dramatic consequences for their own psychological wellbeing.

Key words: breast reduction, cosmetic surgery, body image, decision-making, self-esteem, mother–daughter relationship,

INTRODUCTION

This study aims to explore the influence of psychosocial factors in the decision-making process surrounding breast reduction surgery, and more particularly how the mother–daughter relationship affects these factors and is in turn affected by them. The research aimed to investigate the effect that a daughter’s decision to proceed with surgery might have on her mother, and the subsequent effect on their relationship of the mother’s decision to proceed. At the core of these decisions are the psychological influences of body image, which, research has shown (Sarwer et al., 1998) include

perceptual, developmental and sociocultural factors (Sarwer et al., 1998).

Searches of Pub Med (PM) and PsychINFO’s (PI) databases for publications regarding body dissatisfaction/satisfaction or body image yielded 1,250 (PM) and 726 (PI) citations from the 1970s, 1,785 (PM) and 1,428 (PI) from the 1980s and 2,766 (PM) and 2,477 (PI) from the 1990s (Pruzinsky and Cash, 2002). This may indicate to us that the role of psychosocial factors and their level of impact on body image and body perception has come more to the forefront of research.

Size of body parts (including Body Mass Index) has been linked to a variety of psychosocial concerns (Cash et al. 1991), as has negative body image (Cash & Pruzinsky, 1990). These include social anxiety, low self-esteem, preoccupation with social evaluation, and elevated public self-consciousness (Streigel-Moore et al., 1993; Akan & Grilo 1995)

METHOD

Sampling and Sample

For the present study a sample of 12 female patients of a plastic surgery hospital was used. This sample consisted of six mother–daughter pairs, since the aim of this study was to investigate whether the mother–daughter relationship had any impact or influence in the decision-making for a breast-reduction cosmetic operation. For the selection of the participants the following criteria were used:

1. each woman had to be in the age range of 18–60 years old;
2. each had to be fluent in English;
3. each should have undergone bilateral breast reduction (BBR);
4. there should be a biological mother–daughter relationship in each pair.

According to the formal medical records all the participants had breast sizes that were above average (C–D cup in the UK); two had different-sized breasts (breast asymmetry); six suffered back pain because of the abnormal weight of their breasts.

To eliminate any variations in clinical experience and surgery technique, the sample was taken from the list of one single surgeon. Because of the limited sample a high response rate was necessary for the research aims of this study, so the questionnaires were administered by the therapist who also works as patient co-ordinator for the surgeon. Participation was voluntary. All the questionnaires and results collected were strictly confidential; information contained on the questionnaires was not revealed to any members of the hospital, and the results were made anonymous for the purposes of reporting.

Design and Procedure

The questionnaires were administered during interviews with the participants: six of these were face-to-face interviews in the participant’s home, and six were conducted over the telephone because of a large geographical distance between the researcher and participant. The questionnaire (see Appendix 1) asked the participant to tell the story of her r decision to have a breast reduction operation, her experience of the process and whether she was affected on any level. Additional questions were prepared to prompt coverage of any important areas that the participant might not have discussed. These were interviews were recorded and then transcribed.

All had signed consent forms for use of their medical records, which in some cases included the use of their pre- and post-operative photographs.

RESULTS

Motivation

“…individuals’ own subjective experiences of their appearance were often even more psychologically powerful than the objective or social ‘reality’ of their appearance.” Cash (2004).

All the women interviewed reported similar motivations for wanting to proceed with surgery. All the women had larger than average breasts, with one woman having severe asymmetry (a C-cup breast on one side, and an H-cup on the other).  They felt conspicuous, old for their years, treated like freaks and excluded from the social norm:

“[I] was getting what I call an old lady’s shape … I had that very motherly look” (M2)

“[On holiday I could wear] only Granny clothes.” (D4)

“I could not wear what I wanted; dresses did not fit and I did not want to wear big jumpers and look frumpy.” (D4)

“even if you were not trying to look like a sack you ended up looking like one.” (D1)

“[I] was getting quite agoraphobic” (D6)

Each of the women in the sample claimed that she felt physically, socially and psychologically uncomfortable having outsized breasts, something that was reinforced by people’s reactions: gawping at their breasts, sarcastic remarks, leering looks and cynical comments, usually from men:

“[The attention drawn by her breasts] made me feel more uncomfortable and it upset me quite a lot and I didn’t go out very much at all … I felt people were looking at my body rather than my face.” (D1)

“Breasts are page 3 and they pigeon-hole you.” (D6)

“I was seen as a pair of breasts. I would try to compensate but afterwards I always felt bad.” (D4)

“…when I was 14 and 15 [boys made] comments like ‘Oh you didn’t grow those sitting by the fire’.” (M3)

“I grew to expect men making comments. But women say things that are really hurtful … it is not something that you want to have to put up with.” (D4)

Such humiliation didn’t just arise in the social sphere; the women reported similar occurrences in workplace and healthcare situations. For a number of them, the embarrassment was sometimes overwhelming:

“[Interviewee’s daughter] does sign language for the deaf … and … she could see that people were not looking at the hands they were looking at her breasts … It takes everything away from you, doesn’t it?” (M3)

“I had this one lecturer … when I was a student – he just looked at me constantly and made comments.” (D4)

“I went for a mammogram … and that was awful. I felt acutely embarrassed. … They put your breasts on a plate and she said ‘I will have to get a bigger plate, dear’.” (M5)

The attention attracted by the large breasts didn’t only affect the women in question; it had an impact also on their friends and family. For example, one woman reported how her friends would get defensive on her behalf, and her brother was arrested for an altercation in a pub when he was defending her. She was also hit in the fact by a man when she objected to his comments.

Some endured physical pain, such as backache, and difficulty in walking and certainly running.

On a psychological level, these people were being rejected not only by strangers but also by their peers and social circles as well as by the very professionals who one would think would help them. These people were subjected to rejection from all sides for something that they had no control over.

Surgery

With each of the pairs of women interviewed, without exception, it was the daughter who first decided to have the breast reduction. Body dissatisfaction seem to be extraordinarily prevalent among female college students; perhaps some element of the college experience itself, such as the striving for achievement, contributes to the high prevalence of body dissatisfaction found in this population. (Silverstein et al., 1990; Streigel-Moore et al., 1990). With cosmetic surgery holding such a high profile these days, it has become acceptable for women around 20 years of age to consider such a procedure. The press and television have a large role to play in normalising woman taking charge of their bodies and being prepared to evoke change by drastic measures such as surgery. Pearl and Weston (2003) found that even pupils in the junior class at high school level described people who have cosmetic procedures as “motivated”.

For their mothers it was not. They were born into an era where their shape was their lot in life:

“I was always unhappy with them but I just thought it was me and that was I how I was made to be; it felt a part of me.” (M3)

“I thought it was meant to be … I am supposed to be like this.” (M3)

“plastic surgery and corrective surgery was not something I had thought about; it was just something in the back of my mind I wished I could do something about it … I kept having feelings that … it was a bit selfish of me almost.” (M2)

Our maternal archetype is an image of a large breasted woman. Cash, Ancis and Strachan (1997) found that specific gender attitudes and role expectations at the level of male–female social interactions were associated with more dysfunctional assumptions about the importance of one’s physical appearance. Woman with traditional attitudes about male–female relations were found to be more invested in their appearance, have greater internalization of socio-cultural attitudes towards their appearance, and greater dysmorphic body-image experiences compared to woman with less traditional values.

It was only when they saw their daughters suffering in similar ways and realized that something could be done for them did these mothers take the first steps towards thinking that they too could be changed. Moreover, seeing the results for themselves and the change in their daughters’ confidence and life-style, it seemed that most barriers were knocked out of the way.

“Seeing how well it went for her really just pushed me into it.” (M2)

“She kept telling me, ‘You should have it done, Mum; you should do it, Mum … if [daughter] had not had it done I would never ever, but because she was so happy and it made such a difference to her life… I thought I would never be able to do this and then [daughter] encouraged me.” (M3)

“I think it really stopped my mum doing things. She was very self-conscious. When she saw the difference [in her daughter] that decided her. I didn’t want to push her but I could see how much she would benefit.” (D4)

Most mothers said that if it had not been for their daughter wanting to go right ahead and have the operation, they would not have considered it a possibility for them. In addition, the daughters sometimes had an influence on the possible negative reactions from their fathers:

“Dad was a bit concerned about the operation … but when he saw me a totally different person after the operation … that is why he was happy for my Mum to go for the operation.” (D1)

Outcomes

Cosmetic surgery patients often look for more than changes in their physical appearance. They would like the procedure that they undergo to lead to improvements in things like quality of life, self-esteem and body satisfaction. Grossbart & Sarwer (2003).

In every case in this study, the response to the operation was positive and life changing. Every client interviewed reported that it was the best decision they had ever made.

“My daughter says it is the best thing that ever happened.” (M2)

“It was a big decision to make but I am glad I made it now. I can run, I can walk and I feel like I look like other people now. I’ve got a neck!” (M3)

“Standing up is so strange. I feel so much nicer … straight away I felt free.” (D4)

“Since the reduction I can walk out … I feel more confidence … You know the attention you are going to get is in a good way.” (D1)

“Now I am me and men can take me as I am. Before I was just like a pair of boobs.” (D4)

All spoke of increased confidence and happiness. Immediately after the operation (and in one case for weeks before while the operation was pending) patients were wreathed in smiles of delight and relief. A totally new life and perception of it had opened up for them – overnight. There was little or no objection to any initial bruising after the procedure and no complaints of pain or discomfort. Some women had had misgivings about hospital, surgery and even needles but there were hardly any negative comments concerning this once the results of the operation were appreciated.

DISCUSSION

To women reporting low self-esteem because of their appearance, the situations described above were devastating. One of the participants reported how she felt she couldn’t go into a changing room to be measured for a pretty new bra, and women that could, simply wouldn’t understand what it felt to be coping with her shape. Participant M3 told of how, as a girl, even among her closest friends, she would dress and undress quickly when they were out of the room. This girl was embarrassed by her body in much the same way that people with disfigurement are. In this society we aim to help and protect the disfigured, but for oversized breasts there is very little compassion or for that matter assistance available.

The value of a procedure like this for women facing the social and emotional, to say nothing of the physical, disabilities that they faced, cannot be exaggerated. The change in their lives is nothing short of phenomenal. Immediately, they can walk (and run) out in the community without being in any way peculiar. Instead of shopping being a nightmare, a totally negative experience, it became a pleasure. The excitement both mothers and daughters felt about looking at strappy tops and pretty bras was unanimous. The relief of ‘just being like everybody else’ was more than they could put in words. Studies bear evidence that most patients report improvements in their body image postoperatively (Bolton et al., 2003, Cash et al., 2002, Sarwer et al., 2002).

Now although these incidents are not in themselves all that extraordinary in today’s society, the unusual thing about them is that each one stems from the fact that each woman felt that the circumstances were a direct result of looking abnormal, resulting in them becoming a target for abuse and harassment from men as well as exclusion from “normal” women. Cosmetic surgery patients frequently speak of the emotional pain of being teased about their appearance even decades after the teasing (Sarwer & Crerand, 2004).

The younger generation of women in this study (the daughters) shared with their mothers the embarrassment and humiliation their physical appearance caused them. But unlike their mothers they didn’t feel that cosmetic surgery might have a stigma attached. Their willingness to consider surgery in some cases came as a surprise to their mothers, who had considered their own personal physical burden inescapable. One of the mothers also spoke of her guilt at having passed this burden on to her daughter:

“I used to think it was my fault that she was like that … It came from me, didn’t it?” (M3)

The mothers saw their own genetic inheritance in their daughters’ physical similarity, but also saw history repeating itself as their daughters began to experience the same social and emotional traumas that they had. Once the daughters had gone ahead and had the operation, it was as though an alternative future had been presented to the mothers. Instead of taking the same paths as their mothers through their lives (of embarrassment, humiliation, hiding away) they had taken a new turning that led them to self-confidence, to ‘normality’ and, most importantly, to happiness. This was now a model that the mothers could use to shape their own lives; the roles had been reversed and the mothers were now following their daughters.

CONCLUSION

So, in all six pairs of mothers and daughters, the story has a ‘happy ending’ of increased confidence, physical comfort and an approach to life which is in common with their peers. Because of the unanimity of the response of both mothers and daughters, although the case studies are relatively few in number, this subject would bear further research.

REFERENCES

Akan, G.E. & Grilo, C.M. (1995) Sociocultural influences on eating attitudes, behaviours, body image & psychological functioning: A comparison of African-American, Asian-American & Caucasian college women. International Journal of Eating Disorders, 18, 181-187

Bolton, M.A., Pruzinsky, T., Cash, T.F. and Persing, J.A. (2003) Measuring outcomes in plastic surgery: Body image and quality of life in abdominoplasty patients. Plastic and Reconstructive Surgery 112: 619-625

Cash, T.F., Duel, L.A. & Perkins, L.L.(2002) Women’s psychosocial outcomes of breast augmentation with silicone gel-filled implants: A 2-year prospective study. Plastic and Reconstructive Surgery 109: 2112-2121

Cash, T.F. (2004) Body image: past, present, and future. Body Image: An International Journal of Research. 1(1): 1-5

Cash, T.F., Ancis, J.R. & Strachan, M.D. (1997) Gender attitudes, feminist identity, and body images among college women. Sex Roles 36: 433-447

Cash, T.F., Wood, K.C., Phelps, K.D. & Boyd, K. (1991) New assessments of weight-related body-image derived from extant instruments. Perceptual and Motor Skills 73: 235-241

Cash, T.F. &  Pruzinsky T. (Eds.) (1990). Body Images: Development, Deviance & Change. New York: Guilford Press

Grossbart, T.A. & Sarwer, D.B. (2003) Psychological issues and their relevance to the cosmetic surgery patient. Semin Cutan Med Surg. Jun; 22(2): 136-147

Pearl, A. & Weston, J. (2003) Attitudes of adolescents about cosmetic surgery. Ann Plast Surg. Jun; 50(6): 628-630

Pruzinsky, T. & Cash, T.F. (2002) Understanding body images: Historical and contemporary perspectives. In Cash, T.F. & Prudinsky, T. (Eds.) Body Image: A Handbook of Theory, Research and Clinical Practice. New York: Guilford Press: 3-12

Sarwer, D.B. & Crerand, C.E. (2004). Body image and cosmetic medical treatments. Body Image 1(1): 99-111

Sarwer, D.B., Grossbart, T.A. & Didie, E.R. (2002) Beauty and society. In Kaminer, M.S., Dover, J.S. & Arndt, K.A. (Eds.), Atlas of Cosmetic Surgery. Philadelphia: W.B. Saunders: 83-90

Sarwer, D.B., Wadden, T.A. and Whitaker, L.A. (2002) An investigation of changes in body image following cosmetic surgery. Plastic and Reconstructive Surgery 109: 363-369

Sarwer, D.B., Bartlett, S.P., Bucky, L.P., LaRossa, D., Low, D.W., Pertschuk, M.J., Wadden, T.A. and Whitaker, L.A. (1998) Bigger is not always better: Body image dissatisfaction in breast reduction and breast augmentation patients. Plastic and Reconstructive Surgery 101: 1956-1961

Silverstein, B., Carpman, S., Perlick, D. & Perdue, L. (1990) Non-traditional sex-role aspirations, gender identity conflict and disordered eating among college women. Sex Roles 23: 687-695

Streigel-Moore, R.H., Silberstein, L.R. & Rodin, J. (1993) The social self in bulimia nervosa: Public self consciousness, social anxiety, & perceived fraudulence. Journal of Abnormal Psychology 102: 297-303

Streigel-Moore, R.H., Silberstein, L.R., Grunberg, N.E., & Rodin, J. (1990) Competing on all fronts: Achievement orientation and disordered eating. Sex Roles 23: 697-702

APPENDIX 1

The questionnaire used for the interview:

The interview took the following form:

Every individual’s experience of Bilateral Breast Reduction is unique.

You are one of a distinctive group as either your mother or daughter has undergone a Bilateral Breast Reduction too.

Please tell me your story - Starting from when you first felt that you had a concern up to how you feel today.

For this study, I am looking particularly at the change in self-image pre and post operation and would like to know:

Does the post operation perceived change in self-image of the daughter affect the mother’s decision to have Bilateral Breast Reduction too? If not what does?

Questions to ask if not covered in the story

1. Physically, what change did you want?
2. What did you get?
3. What did you expect to achieve physically?
4. What breast size did you want to achieve?
5. What breast size do you have now?
6. How did you feel about your body before the operation?
7. How do you feel now?
8. How do you feel about this result?
9. What was your self-image before the operation?
10. How did it change after the operation if at all?
11. What do others say about your result?
12. What changed in your life because of your smaller breasts?
13. How did you perceive yourself with regard to the size of your breasts in certain situations i.e. peer group/ social group compared to your friends/social group before the operation?
14. What do you look like compared to your friends/social group now?
15. Do you think people treat/react to you differently?
16. How do you think the decision to have this operation has changed your life if at all?
17. What impact did the change in daughter’s self-image have on mother’s decision to have surgery if at all?
18. Why did Daughter have operation first?
19. Why did you choose to have the surgery?
20. What made you decide to have yours?
21. Did they way your daughter felt about her results affect your decision to have surgery?
22. Would you advise other members of your family with the same scenario to have the same surgery?
23. Do you think that people treat you differently now and if so why?
24. How if at all how has your personality changed after surgery?
25. How does the way you look now affect your new self-image if at all?
26. How has Mother’s self-image changed post op if at all?