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Vivienne Purcell
Understanding
Visible Differences
Working Therapeutically
With Individuals Who Look Different
Vivienne Purcell
Lyndhurst, Hampshire, UK
ISSN 2662-9127 ISSN 2662-9135 (electronic)
Palgrave Texts in Counselling and Psychotherapy
ISBN 978-3-030-51654-3 ISBN 978-3-030-51655-0 (eBook)
https://doi.org/10.1007/978-3-030-51655-0
© The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer Nature
Switzerland AG 2020
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and
transmission or information storage and retrieval, electronic adaptation, computer software, or by similar
or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or
the editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
Cover illustration: Flavio Coelho/gettyimages
This Palgrave Macmillan imprint is published by the registered company Springer Nature Switzerland AG.
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Author’s note—all comments attributed to interviewees have
been viewed and approved by them prior to publication.
All case examples and material used to facilitate understanding
of issues have been anonymised and do not refer to identifiable
clinical cases.
Acknowledgements
I have written this book as a resource for supervisors, therapists, their
clients and those caring others who wish to understand more. It is
intended to be a brief and wide-ranging work to complement those spe-
cialist reference books which are excellent clinical resources. It is the one
I often wished for in busy supervision sessions.
The generous contributions of interviewees who were willing to share
their own experiences of caring for, adjusting to and living with differ-
ence have been invaluable. I’d like to thank Jo Williams, Kenny Ardouin,
Beth Angella, Sasha Lynne, Kay Kay, Paul McSharry and Beth Shaw in
particular, for their time and openness. Their approval was sought for all
interview comments used prior to publication.
Finally, huge thanks to Arlene Vetere, Rudi Dallos, Mike and Kit Neill
whose help, belief and encouragement I have been able to rely on.
vii
An Overview: ‘Naming and Fear’
Even in a multicultural society most people have little difficulty in recog-
nising others whose physical appearance is outside the norm. Historically
human social groups are formed by blood ties which amplify and assign
value to recognised similarities and geographic interests, and appearance is
an important signifier of ‘people like us’, often reinforced by marriage/part-
nership patterns (Berry 2000). Favoured and disfavoured characteristics
within social groups are to some extent historically/socially formed, and as
such are mediated by status and variable over time, but also impacted by
the resources and survival needs of the group. Tradition matters, and nor-
malises beliefs and behaviours. Mary Douglas, in her early anthropological
work Purity and Danger (1966), studied how these patterned beliefs main-
tain symbolic boundaries in ritual, religion and lifestyle.
It does not take much imagination to realise that a person with physi-
cal differences outside the normal range and/or limitations may fre-
quently confer fewer advantages on a small isolated human group. Such
differences may be tolerated more easily in an adult (say) who is injured
in battle but has knowledge and/or wisdom to share, than a dependent
child. Female, and to a lesser extent male, children whose marriageability
is affected by physical defects are also more likely to be regarded as liabili-
ties or sources of shame in honour-based cultures.
ix
x An Overview: ‘Naming and Fear’
Historically in many traditional societies infants or adults that looked
different at birth would be ostracised or killed, with superstitious beliefs
associated to them, such as fearing they would bring bad luck, and there
are examples today of communities which regard having a different or
disabled child as shaming. The African Child Policy Forum (ACPF)
(2011) based on field studies in Cameroon, Ethiopia, Senegal, Uganda
and Zambia concluded that ‘common beliefs about the causes of child-
hood disability include: sin or promiscuity of the mother, an ancestral
curse; or demonic possession’ (Eskay et al. 2012). The prospects for such
children and their mothers can be very bleak, particularly in groups with
limited resources. More hopefully in Nigeria there has been a public edu-
cation campaign and dissemination of disability-related information
with the intention of overcoming persistent false beliefs about disability.
These previously included a curse from God, ancestral violations of social
norms, offences against the local Gods, witches and wizard actions, adul-
tery and more.
These beliefs may at first seem outlandish, but in the UK the discovery
of disability during pregnancy frequently results in a termination where
there are no strong counter beliefs. For example, 63% of foetuses identi-
fied with spina bifida and 83% of those with anencephaly were aborted
(Johnson et al. 2012). Few loving parents would choose a disability for
their child, and they are encouraged to ‘try again’ by doctors, hoping for
one that is able-bodied, clever and beautiful, or at least average.
In all cases stigmatising messages and behaviours aimed at individuals
or minorities create anxiety and avoidance which may be experienced at
a group, family and individual level. Those who look different report a
routine loss of privacy caused by staring and personal comments, which
can be very aversive. Exposure to aversive experiences without under-
standing, support and help to manage these interactions creates psycho-
logical distress. Without this, fearful predictions of similar upsetting
experiences in future social interactions can result in a pattern of low
self-esteem, shame and associated negative feelings and behaviours, limit-
ing the interactions and opportunities of those who have been stigmatised.
For clinical work to succeed there must be sufficient therapeutic alli-
ance to permit focus on these internalised thoughts and feelings, without
reactivating shame, so that over time the individual expands their social
An Overview: ‘Naming and Fear’ xi
network and comes to believe that any ignorance and prejudice they
encounter are the problem of the other, rather than internalising it. They
also need to acquire skill and understanding in social interactions to
manage the natural curiosity of others when they encounter difference.
References
African Child Policy Forum (2011) Violence against children with disabilities in
Africa: field studies. Cameroon, Ethiopia, Senegal, Uganda and Zambia
Berry DS (2000) Attractiveness, attraction, and sexual selection: Evolutionary
perspectives on the form and function of physical attractiveness. Advances in
Experimental Social Psychology 32:273–342. Elsevier
Douglas M (1966) Purity and danger: an analysis of concepts of pollution and
taboo. Routledge and Keegan Paul
Eskay M, Onu VC, Igbo JN, Obiyo N, Ugwuanyi L (2012) Disability within
the African Culture 478, University of Nigeria, Nsukka, US-China Education
Review B2. Source: www.un.org-socdev-disability. Toolkit on Disability
for Africa
Johnson C et al (2012) Pregnancy termination following prenatal diagnosis of
anencephaly or spina bifidia: a systematic review of clinical literature. Birth
Defects Research Part A Clinical Molecular Teratology 94(11):857–863
Contents
1 What Do We Mean by ‘Visible Difference’? 1
2 The Social Construction of Difference and Disability 11
3 The Developing Self: The Differences of Difference 33
4 The Family Context 59
5 Relationships: Outside of the Family Group 77
6 Assessment and Treatment Planning 95
7 Healing Conversations115
8 Thinking About Treatment Plans and Models: A
Formulation-Based Approach131
xiii
xiv Contents
S
ome Final Thoughts155
Appendix: Brief Summary of Types of Visible Difference159
Resources Support and Information169
Index175
List of Figures
Fig. 8.1 Factors for treatment plans 132
Fig. 8.2 CBT basic formulation example 135
Fig. 8.3 Three areas formulation diagram 137
Fig. 8.4 Diagram adapted from Lee (2009) 142
Fig. 8.5 Anita’s ‘Bottom Line’ (schema, core belief ) global
negative self-judgement (or feared truth). Adapted from
Lee (2009) 152
xv
List of Tables
Table 8.1 Her treatment diagram looked something like this 143
Table 8.2 His treatment diagram looked like this—(20+ sessions) TBA 147
xvii
1
What Do We Mean by ‘Visible
Difference’?
A Story
Grownups often said what a lovely brave boy Jack was. He didn’t really
know why. The children at school said different things—‘what’s wrong
with your face?’ or ‘weirdo’, or some other stupid thing. Sometimes a few
of them called names, pretended ‘it’ was catching, screamed and ran
away, then said it was just a game. Especially if he had been in hospital for
some surgery on his face and the swelling hadn’t completely gone. Though
Jack was used to how he looked even he thought he was a bit scary weird
then. Teachers usually stopped the game when they found out, eventu-
ally. Once, during circle time at Whitegates Primary, Mr. Davies talked
about the ways that people could be different and what it meant, and Jack
had a chance to explain his difference and how he was born that way
which helped. Luckily, another girl in the class talked about her differ-
ence too, which was a relief. Then she wanted to hang out with Jack all
the time, but she was a bit annoying so he tried to avoid her. He felt sorry
when she cried, but also fed up that everyone thought they should play
together because they were both different. There was more to friendship
than that he thought! Usually he made one or two friends, never any of
© The Author(s) 2020 1
V. Purcell, Understanding Visible Differences, Palgrave Texts in Counselling and
Psychotherapy, https://doi.org/10.1007/978-3-030-51655-0_1
2 V. Purcell
the really popular people, but there were always a few odd ones in every
class, quiet or sad or awkward. Or just smarter than everyone else. They
were more interesting and they got used to him. His dad was in the army,
so he had been to a few schools and knew how to get by, act tough when
he needed to. When things were really bad, he found ways to be on his
own, reading, playing games, making things, or out in the wilds if he
could find any.
He was in the last year of primary now, and due to go to secondary
school in the autumn. Things had got better here over time, and everyone
in the class seemed OK with him mostly. Jack and his friend Nick liked
to play in the fields behind the houses, which led all the way up to the
woods at the top. From there they could see far away to Oxford some-
times, and watch the kites circling in the thermals. Both of them loved
birds, and Nick’s dad worked at the bird sanctuary. It was here he learned
how to hold them on his arm in the field, release their hoods and let them
fly. It was the most fantastic feeling he knew, even better than running
and shouting in the dark on the way home. He felt his heart lift with
them and imagined what it was like to soar free above everything. Getting
them to return to the lure was a bond, a connection to something wild.
It was a safe place.
Like his dog Jessie, the birds didn’t care what Jack looked like, it was
just about trust and heart and fun. He thought that was probably a kind
of true love because his mum and dad often said the way he looked didn’t
matter, and not to mind when people said silly things. Mum said that
when people get to know you they see who you really are. That made
sense to Jack, because with every operation he looked a bit different. He
thought one day the surgeons might make him look normal, which
would be a relief though it shouldn’t matter.
Generally, Jack was fine. There were just a few things that really both-
ered him. Like never being picked for the football team, when he thought
some of the others who got picked regularly weren’t as good. Nick was
often picked, but he deserved it and Jack went to games to cheer him on.
Sam, who was always in the team liked the glory, but Nick worked inces-
santly to set up the shots and made him look good. That was the way
things seemed to work, Jack thought, some people had it easy.
