Designing an mHealth Intervention for People With Visible Differences Based on Acceptance and Commitment Therapy: Participatory Study Gaining Stakeholders' Input

A multi-centre prospective cohort study investigating the roles of psychological flexibility and self-compassion in appearance concerns after burn injuries

OBJECTIVES

Appearance concerns following burn injuries are common. Psychological factors are important in maintaining such concerns. However, there is a lack of longitudinal or prospective research investigating their development. This study investigated whether psychological flexibility and self-compassion at hospital admission predicted subsequent appearance concerns.

DESIGN

A multi-centre prospective cohort study across six burn services.

METHODS

Adults (n = 175; 67% male) in hospital following burn injuries were recruited. Questionnaires measuring appearance concerns, psychological flexibility, self-compassion, post-traumatic stress disorder symptoms and perceived noticeability were completed during hospital admission and two- and six-months later. Demographic and burn injury information was collected.

RESULTS

Correlational analyses showed that increased psychological flexibility and self-compassion at admission were associated with decreased appearance concerns cross-sectionally and prospectively at two- and six-month follow-up. These associations remained significant when controlling for key covariates (i.e. gender, age, ethnicity, percentage total body surface area burnt, perceived noticeability, PTSD symptoms). Multiple linear regression analyses revealed that psychological flexibility and self-compassion predicted appearance concerns during hospital admission. Although psychological flexibility significantly predicted appearance concerns over time, it became non-significant when controlling for baseline appearance concerns.

CONCLUSIONS

Psychological flexibility has a protective role against appearance concerns soon after burn injuries, although this protective role is reduced when accounting for baseline appearance concerns. Early interventions targeting psychological flexibility (i.e. acceptance and commitment therapy) may be beneficial after burns if adapted to address appearance-related concerns.

More than my appearance: a pilot evaluation of the expand your Horizon Online functionality-based writing programme for adults with visible differences

Background

Adults with conditions that affect their appearance, known as visible differences, can experience appearance concerns, social anxiety, and depression. Interventions have been developed for this population to facilitate adjustment and coping skills; however, they have limited evidence of efficacy. The Expand Your Horizon [Alleva, J. M., Martijn, C., Van Breukelen, G. J., Jansen, A., & Karos, K. (2015). Expand Your Horizon: A programme that improves body image and reduces self-objectification by training women to focus on body functionality. Body Image, 15, 81-89. https://doi.org/10.1016/j.bodyim.2015.07.001] online functionality-based writing programme was adapted for adults with visible differences.

Method

A pilot randomised controlled trial with a wait-list control group was carried out to assess preliminary intervention efficacy and gain information about the acceptability and feasibility of the programme. Forty-four adults aged 21-63 years (M = 40.21; SD = 12.05) with visible differences took part. Various facets of body image (i.e. functionality appreciation and body appreciation) as well as depression and anxiety were assessed immediately pre- and post-intervention and at three-months.

Results

Participants reported enjoying the programme, felt that the format was acceptable, and it significantly increased functionality appreciation, which was maintained at three-months. However, there were no improvements in body appreciation, depression, and anxiety.

Conclusions

In future, a full trial should be carried out with an active control group.

Assessing saliency models of observers' visual attention on acquired facial differences

Purpose

Saliency models that predict observers' visual attention to facial differences could enable psychosocial interventions to help patients and their families anticipate staring behaviors. The purpose of this study was to assess the ability of existing saliency models to predict observers' visual attention to acquired facial differences arising from head and neck cancer and its treatment.

Approach

Saliency maps predicted by graph-based visual saliency (GBVS), an artificial neural network (ANN), and a face-specific model were compared to observer fixation maps generated from eye-tracking of lay observers presented with clinical facial photographs of patients with a visible or functional impairment manifesting in the head and neck region. We used a linear mixed-effects model to investigate observer and stimulus factors associated with the saliency models' accuracy.

Results

The GBVS model predicted many irrelevant regions (e.g., shirt collars) as being salient. The ANN model underestimated observers' attention to facial differences relative to the central region of the face. Compared with GBVS and ANN, the face-specific saliency model was more accurate on this task; however, the face-specific model underestimated the saliency of deviations from the typical structure of human faces. The linear mixed-effects model revealed that the location of the facial difference (midface versus periphery) was significantly associated with saliency model performance. Model performance was also significantly impacted by interobserver variability.

Conclusions

Existing saliency models are not adequate for predicting observers' visual attention to facial differences. Extensions of face-specific saliency models are needed to accurately predict the saliency of acquired facial differences arising from head and neck cancer and its treatment.

A brief online writing intervention improves positive body image in adults living with dermatological conditions

Introduction

Dermatological conditions can affect how individuals feel about their bodies. This research therefore seeks to evaluate the potential for a brief writing intervention, focused on body functionality, to improve body image in adults living with a range of dermatological conditions.

Methods

As part of a parallel Randomised Controlled Trial, 451 adults living with a dermatological condition were randomized to either three functionality-based writing tasks or three creative writing tasks (control). Of these, 155 participants completed pre- and post-intervention measures of body appreciation, functionality appreciation, appearance anxiety, skin-related shame, and skin-related quality-of-life.

Results

For participants with relatively low or mid-range scores on baseline body appreciation and functionality appreciation, there were medium-to-large positive effects of the intervention. Effects were smaller, with all but-one remaining significant, at 1-month follow up and in intention-to-treat analyses. No between-group effects of the intervention were found for measures of appearance anxiety, skin-related shame, and skin-related quality-of-life.

Discussion

These findings suggest that a 1-week writing intervention has the potential to improve positive aspects of body image, but not appearance- and skin-related distress in adults living with a dermatological condition.

Clinical trial registration

[https://clinicaltrials.gov/ct2/history/NCT044459 74?V_3=View], identifier [NCT04445974].

An Acceptance and Commitment Therapy Prototype Mobile Program for Individuals With a Visible Difference: Mixed Methods Feasibility Study

Background

Mobile apps may offer a valuable platform for delivering evidence-based psychological interventions for individuals with atypical appearances, or visible differences, who experience psychosocial appearance concerns such as appearance-based social anxiety and body dissatisfaction. Before this study, researchers and stakeholders collaboratively designed an app prototype based on acceptance and commitment therapy (ACT), an evidence-based form of cognitive behavioral therapy that uses strategies such as mindfulness, clarification of personal values, and value-based goal setting. The intervention also included social skills training, an established approach for increasing individuals’ confidence in managing social interactions, which evoke appearance-based anxiety for many.

Objective

In this study, the authors aim to evaluate the feasibility of an ACT-based app prototype via the primary objectives of user engagement and acceptability and the secondary feasibility objective of clinical safety and preliminary effectiveness.

Methods

To address the feasibility objectives, the authors used a single-group intervention design with mixed methods in a group of 36 participants who have a range of visible differences. The authors collected quantitative data via measures of program use, satisfaction ratings, and changes over 3 time points spanning 12 weeks in outcomes, including selected ACT process measures (experiential avoidance, cognitive defusion, and valued action), scales of appearance concerns (appearance-based life disengagement, appearance-fixing behaviors, appearance self-evaluation, and fear of negative appearance evaluation), and clinical well-being (depression and anxiety). Semistructured exit interviews with a subsample of 12 participants provided qualitative data to give a more in-depth understanding of participants’ views and experiences of the program.

Results

In terms of user engagement, adherence rates over 6 sessions aligned with the upper boundary of those reported across mobile mental health apps, with over one-third of participants completing all sessions over 12 weeks, during which a steady decline in adherence was observed. Time spent on sessions matched design intentions, and engagement frequencies highlighted semiregular mindfulness practice, mixed use of value-based goal setting, and high engagement with social skills training. The findings indicate a good overall level of program acceptability via satisfaction ratings, and qualitative interview findings offer positive feedback as well as valuable directions for revisions. Overall, testing for clinical safety and potential effectiveness showed encouraging changes over time, including favorable changes in appearance-related life disengagement, appearance-fixing behaviors, and selected ACT measures. No iatrogenic effects were indicated for depression or anxiety.

Conclusions

An ACT-based mobile program for individuals struggling with visible differences shows promising proof of concept in addressing appearance concerns, although further revisions and development are required before further development and more rigorous evaluation.