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The challenge of developing comprehensive models and theories to guide and underpin
research relating to appearance have been discussed by Thompson and Kent (2001) and
Rumsey and Harcourt (2005). Early cognition models of body image disturbance focused on
the discrepancy between an individual’s perceived actual and ideal selves, and described the
process by which an individual’s thinking can become more and more dominated by negative
thoughts about their appearance (Thompson et al 1999). Cash’s (1997) cognitive-behavioural
model recognizes that past, cultural and interpersonal experiences, physical characteristics and
personality attributes influence the development of body image attitudes and schema.
In relation specifically to disfigurement, perspectives on stigma (Goffman 1963), shame (Kent &
Thompson, 2002) and social exclusion (Leary 1990) have all informed the development of a
number of models. Some researchers (including members of this collaboration) have
developed models of the processes involved. For example, Kent (2002) proposed a model
centred around appearance anxiety and stigma. Newell (2000a) developed a testable
fear/avoidance model of social anxiety among people with a visible difference, proposing a
continuum of confrontational and avoidant responses (as opposed to discrete categories of
good or bad adjustment). More recently, Moss & Carr (2004) explored the use of the multifaceted
self-concept as a means of exploring adjustment to disfigurement. Other models have
attempted to explain appearance issues within specific condition or treatment groups (see, for
example, Sarwer et al (1997) in relation to the motivation to seek cosmetic surgery, White
(2002) in relation to cancer, Thompson (2009) in relation to skin conditions) rigorously
highlighting the influence of developmental, social-cultural and perceptual factors on body
image and self-esteem. Whilst models may help to organise collective thinking, they cannot, at
their current level of sophistication, provide a comprehensive representation of the complexities
of factors, the relationships between these factors and the dynamic nature of adjustment. To
date, no single model stands out as offering a comprehensive framework to guide research and
clinical intervention. The available models are either limited in scope, falling short of providing a
comprehensive understanding of individual experiences of appearance, or incorporate
constructs that cannot easily be measured/assessed. None of the existing models have been
tested on a large and diverse population of people with visible differences. However,
exploratory research has provided such a plethora of variables implicated in experiences and
adjustment, that it was considered timely to marshal them into a manageable format for the
purpose of guiding research.
Mindful of the need to share a common approach to this research and of the imperative to
inform interventions, the members of this collaboration adopted a pragmatic approach in
developing a framework to guide the current research programme. This approach integrated
the main findings and trends in this area of research, encompassing aspects of previous models
developed by members of the team and other leading commentators in the field. The
framework was designed to facilitate the identification and clarification of those factors which
have the potential to be amenable to change through psychosocial support and intervention,
either as an adjunct, or where appropriate, as an alternative to surgical and medical
intervention. In addition, and in contrast to previous research in this area, which has focused in
the main on the problems and difficulties associated with disfigurement, this programme aimed
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