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Dermatology Original Article · Originalarbeit

Psychosomatics
Dermatol Psychosom 2004;5:172–177
Dermatologie
Psychosomatik

Living with Vitiligo: A Controlled Investigation into the


Effects of Group Cognitive-Behavioural and
Person-Centred Therapies
L. Papadopoulosa C. Walkerb L. Anthisa
a Department of Psychology, London Metropolitan University,
b Department of Psychiatry and Behavioural Sciences, University College London, Great Britain

Key Words Schlüsselwörter


Vitiligo · Group psychotherapy · Cognitive-behavioural Vitiligo · Gruppentherapie · Kognitive Verhaltenstherapie ·
therapy · Self-esteem · Body image Selbstwert · Körperbild

Summary Zusammenfassung
Background: Vitiligo is a progressive condition involving Leben mit Vitiligo: Eine kontrollierte Untersuchung der
a loss of pigmentation in the skin. It can be disfiguring Therapieeffekte von kognitiv-behavioraler und person-
and no fully effective treatment or cure exists. Although zentrierter Gruppenpsychotherapie
medical effects of vitiligo have been studied extensively, Hintergrund: Vitiligo ist eine chronisch-progressive Er-
less attention has been paid to its psychological impact. krankung, die mit einem Verlust der Hautpigmentierung
Methods: This research compared the efficacy of group einhergeht. Sie kann entstellend sein und bislang nicht
cognitive-behavioural therapy (CBT) and group person- vollständig behandelt oder geheilt werden. Obwohl die
centred therapy with respect to ameliorating the dis- medizinischen Auswirkungen von Vitiligo intensiv unter-
abling effects of the condition. Participants were ran- sucht worden sind, wurde dessen psychologische Be-
domly allocated to either the control group, the CBT deutung bisher wenig beachtet. Methoden: Die vorlie-
treatment group or the person-centred treatment group. gende Studie vergleicht die Effekte einer kognitiv-verhal-
Participants underwent 8 consecutive weeks of therapy tenstherapeutischen Gruppentherapie (KVT) und einer
and psychological and physiological gains were record- personzentrierten Gruppentherapie auf die einschrän-
ed before therapy, after therapy and at 6 and 12-month kenden Auswirkungen der Erkrankung. Die Teilnehmer
follow-up. The study used a mixed factorial design for wurden zufällig der Kontrollgruppe, der KVT oder der
the questionnaire analysis. The independent factor was personzentrierten Gruppentherapie zugewiesen. Die Teil-
the three different experimental conditions; control, CBT nehmer erhielten 8 Wochen Therapie. Psychische und
and person-centred therapy and the repeated measures physiologische Veränderungen wurden vor, unmittelbar
factor was assessment point; pre-treatment, post-treat- nach sowie 6 und 12 Monate nach Therapieabschluss
ment, 6-month follow-up and 12-month follow-up. Re- untersucht. Die Studie verwendete ein faktorielles Design
sults: Unlike previous work with different psychotherapy mit Messwiederholung. Der unabhängige Faktor waren
formats, little psychosocial or physiological benefits die drei unterschiedlichen experimentellen Bedingungen
were gained as a result of the two group therapy pro- KVT, personenzentrierte Gruppentherapie und Kontroll-
grammes. Conclusion: This research helps us to under- gruppe. Der Messwiederholungsfaktor waren die Mess-
stand more fully the efficacy of psychological therapy zeitpunkte vor und nach der Therapie sowie zur 6- und
with a vitiligo population and will help direct health pro- 12-Monats-Katamnese. Ergebnisse: Anders als bei frühe-
fessionals to the most appropriate format for future use. ren Therapievergleichsstudien führten die beiden psy-
chotherapeutischen Interventionen nur zu geringen
psychosozialen oder physiologischen Verbesserungen.
Schlussfolgerung: Die Studie trägt dazu bei, die Wirk-
samkeit psychologischer Therapien bei Vitiligopatienten
besser zu verstehen, und kann Medizinern helfen, künftig
die am besten geeignete Therapieform zu wählen.
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© 2004 S. Karger GmbH, Freiburg Dr. Carl Walker


Department of Psychiatry and Behavioural Sciences
Fax +49 761 4 52 07 14 Accessible online at: Royal Free and University College Medical School
E-mail Information@Karger.de www.karger.com/dps Rowland Hill Street, GB-London, NW3 2PF
Glasgow Univ.Lib.
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www.karger.com Tel. +44 208 472 6830


E-mail c.walker@rfc.ucl.ac.uk
Until recently [Kent, 2000; Van Moffaert, 1992; Gil et al., with a larger sample and a non-treatment control group and
1987], there has been relatively little interest in the psycho- a control group consisting of vitiligo patients receiving indi-
logical aspects of disfiguring medical conditions. Much of the vidual person-centred therapy, Papadopoulos et al. [personal
research in this area has been published in medical journals, data] showed that only individual CBT effectively addressed
where the primary concern has been the assessment of the so- the body image, self-esteem and quality of life of vitiligo pa-
cial and personal difficulties that can be associated with der- tients. This work suggested that the specific tenets and for-
matological diseases, burns and cranio-facial abnormalities. mat of individual CBT effectively addressed the above vari-
Research into the manifestations of psychocutaneous disor- ables rather than a generic therapeutic alliance. No change
ders has led to an increasing awareness that there are psy- was recorded in the vitiligo depigmentation for any of the
chosocial effects associated with skin disease. These include groups.
depression, an impaired sense of body image, decreased self- Group psychotherapy as it is known today can differ along a
esteem, sexual and relationship difficulties and a general re- series of dimensions including group composition, format,
duction in quality of life [Papadopoulos et al., 1999; Porter et goals and duration. The benefits of group therapy include the
al., 1987; Obermeyer, 1985; Dungey and Busselmeir, 1982]. installation of hope, universality (participants may be able to
They also include a reduced sense of control, predictability benefit from the simple therapeutic value that lies in the reali-
over one’s life and reduced social support [Gieler et al., 2000; sation that they are not the only person suffering from the ef-
Thompson and Kyle, 2000; Picardi et al., 2003]. fects of this condition) and the development of socialising
The visibility of most dermatoses has psychological conse- techniques [Gilbert and Shmukler, 1996]. However, good re-
quences and can often carry connotations of contagion or a search knowledge on group psychotherapy in this medical
lack of hygiene [Papadopoulos and Walker, 2003; Kleinman, context is more scarce than in other areas of medical psy-
1988]. This may cause patients to feel ostracised and the re- chotherapy [Cunningham et al., 1978]. A review of group ther-
sulting self-depreciative feelings may lead to social fear and apy with a number of medical conditions has shown some suc-
shame. Indeed, dysmorphic disorder is characterised by a sub- cess [Ornish et al., 1998; Linden et al., 1996; Bergin and
jective feeling of ugliness, cosmetic defect or deformity in Garfield, 1994; Kelly et al., 1993; Parker et al., 1993; Fawzy et
one’s appearance. al., 1993] on a number of psychosocial variables including hos-
Vitiligo is a progressive skin condition involving the apparent tility, depression, anxiety, symptom management, problem
destruction of the pigment-producing cells in the skin. The af- solving and psychiatric symptoms.
fected areas lose their pigmentation resulting in the appear- The following work has been conducted such that CBT in a
ance of irregular white, non-scaly lesions over the surface of group format can be compared to group person-centred thera-
the skin. Although the general appearance of the patient can py and an untreated control in order to test whether the group
change, the health of the patient is not affected in any other format of CBT is similarly efficacious to the individual format.
way and patients report no physical pain or discomfort [Hann As such, the recruitment process, length of therapy, selection
and Nordlund, 2000]. It is for this reason that the impact of the of counselling psychologists, therapeutic protocols and facili-
condition is often minimised and addressed only in cosmetic ties have been modelled on Papadopoulos et al.’s [1999] previ-
terms. ous work.
Papadopoulos et al. [1998] undertook a rigorous analysis of
the relationship between vitiligo and stressful life experiences
and showed that vitiligo patients experienced a significantly Methods
higher proportion of stressful life events in the year preceding
the onset of their condition than matched controls. Participants
Participants were recruited through an advertisement in the UK Vitiligo
Papadopoulos et al. [1999] showed that an 8-week course of
Society’s quarterly newsletter in June 2000. Participants were also recruit-
individual cognitive-behavioural therapy (CBT) significantly ed over the summer of 2000 from St. Thomas’ Hospital, Whipps Cross
improved vitiligo patients’ self esteem, quality of life and body Hospital, The Ealing Hospital, and The Royal Free Hospital in London.
image. It appears that the CBT programme had a particular Local research ethics approval was secured before recruitment.
impact on the reduction of negative thoughts as opposed to a It was necessary that volunteers:
– were over 18 years of age;
particular increase in positive thoughts. This supports Hart’s
– were formally diagnosed by a dermatologist;
[1982] work with anxious and depressed patients. Further- – had not previously undergone, or were receiving counselling to help
more, and of great interest, the participants who undertook them cope with their condition;
CBT also showed a general decrease in vitiligo depigmenta- – had the condition for at least 1 year;
tion, possibly as a result of the development of stress inocula- – were not taking any form of psychotropic medication.
A power analysis using GPOWER was carried out in order to determine
tion techniques.
the appropriate sample size that would enable treatment effects to be reli-
This research was crucial but limited in that it had a small ably established [Faul and Erdfelder, 1992]. A treatment effect of 0.5 and
sample and only tested the comparative effect of one type of a power of 0.8 revealed that a sample size of 45 (15 participants in each
therapy against a non-treatment control. In an investigation group) would be necessary to reliably detect this treatment effect.
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Group Cognitive-Behavioural and Person- Dermatol Psychosom 2004;5:172–177 173


Centred Therapies of Vitiligo
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Table 1. Number of participants, mean age and standard deviation by Table 3. Ethnicity split by condition
condition
Person-centred CBT Control
Age, years Participants, n
 Caucasian 9 9 9
mean SD
Asian 3 2 5
Afro-Caribbean 2 4 1
Person-centred 35.847 11.718 14
Total 14 15 15
CBT 36.385 12.051 15
Control 37.708 11.094 15

In the case of the person-centred treatment group, it is not possible to


Table 2. Sex split by condition construct a counselling protocol as such, since this therapy is non-direc-
tive, requiring the therapist to follow the client’s lead and reflect and em-
Person-centred CBT Control pathise with the client’s experience. However, core person-centred thera-
peutic conditions such as empathic reflecting, summarising and uncondi-
Female 9 10 12 tional positive regard were observed.
Male 5 5 3 Two therapists provided counselling, one whose principal therapeutic
Total 14 15 15 model is CBT and one whose approach is person-centred. This minimised
the possibility of bias due to the therapists’ expertise and expectations.
Participants completed the first set of questionnaires 1 week before the
sessions. Participants were sent questionnaires after the 8-week thera-
The 45 participants were matched for age, sex and ethnicity and were then py course, at 6 months and at 12 months. Participants also came into
allocated either to the control, the CBT treatment group or the person- the university to be photographed before the treatment schedule, as
centred treatment group (tables 1–3). Due to the need to establish effec- well as 6 and 12 months after the completion of the schedule in order to
tive group dynamics, a decision was made to facilitate two smaller groups monitor the spread of the participant’s vitiligo.
of 8 participants within each treatment. The first CBT group contained A letter was sent to participants explaining the photograph procedure and
8 participants and the second CBT group contained 7 participants, due to it was emphasised that if the participant felt uncomfortable with having
one participant’s failure to arrive at the first session. The first person- the photographs taken then they would not be taken. Similarly, partici-
centred group contained 6 participants (due to 2 participants’ failure to pants were informed that they could drop out of the research process at
arrive at the first session) and the second person-centred group contained any time without giving a reason and that all data that was recorded
8 participants. would be treated confidentially. Participants were asked to have full body
The participants who were allocated to the treatment groups were given shots taken, front and back. Of the 44 participants, 29 participants con-
psychological therapy from a chartered counselling psychologist in one sented to having the photographs taken. Several participants indicated
of the counselling rooms at London Metropolitan University. Therapy that they were only comfortable having the relevant area(s) of depigmen-
lasted for approximately 90 minutes and 1 session per week and was tation photographed. They were given this choice but agreed that if new
undertaken for 8 consecutive weeks. Participants allocated to the control lesions were to appear then they would to have these new lesions pho-
group were not offered counselling and received no change to their tographed also.
treatment status. The conventional treatment status of all participants
was ‘no medical treatment’ which is common for vitiligo patients be- Instruments
cause neither steroids nor PUVA can be used over extended periods. The outcome measures consisted of photographs and a battery of vali-
This lack of treatment status also allowed the conclusion that any dated and reliable questionnaires. The photographs were taken in the
changes in the pigmentary status of the participants would not be due to photography department at London Metropolitan University. They were
external treatment. assessed by researchers who acted as ‘blind’ raters. All photographs were
assessed using the Pajant Photoshop computer analysis package that pro-
Procedure duces objective estimates of any changes in vitiligo spread prior to and
The counselling protocol used for the first group was originally adapted following treatment. The use of this package involves tracing round le-
from the CBT model [Beck, 1976]. The therapy itself focussed on examin- sions and calculating spread as a percentage of body area using pixel
ing and attempting to change negative thought patterns that may be re- counts. Spread was calculated as a percentage in order to account for
sponsible for the individual’s low mood or avoidance of certain situations minor differences due to the camera angle and distance from the lens.
and behaviours. In conjunction with techniques drawn from CBT, the Photographs were scrutinised by dermatologists in order to assess the
counselling protocol also incorporated the teaching of practical skills that presence and visibility of vitiligo.
can be used to address some of the problems that individuals with a visi- The questionnaires used included the Rosenberg Self-Esteem Scale
ble skin disorder may encounter such as staring and comments from [Rosenberg, 1965], The Body Image Automatic Thoughts Question-
strangers. This specific CBT protocol is drawn from Papadopoulos et al.’s naire (consisting of two scales which record positive and negative
[1999] work with vitiligo patients. thoughts independently) [Cash, 1987], The Situational Inventory of
The person-centred approach is based on concepts from humanistic psy- Body Image Dysphoria [Cash, 1994], The General Health Question-
chology. Founded by Carl Rogers in the 1950’s [Woolfe and Dryden, naire [GHQ; Goldberg and Williams, 1988], The Perceived Stress
1996], the basic assumptions state that people are essentially trustworthy, Scale [Cohen et al., 1983] and The Dermatology Quality of Life
that they have a vast potential for understanding themselves and resolving Index [Finlay and Khan, 1994]. Evidence of the reliability and valid-
their own problems without direct intervention on the therapist’s ity of the above measures is satisfactory and has been reported in
part. From the beginning, Rogers emphasises the attitudes and personal several studies [i.e. Finlay and Khan, 1994; Cash, 1994; Rosenberg,
characteristics of the therapist and the quality of the client-therapist 1965].
relationship.
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Table 4. ANOVA results for interactions between group and time point Table 6. T test results for general health at different time points for the
for the multiple dependent variables group therapy comparison

Variable Interaction: group × time point t df p



F df p
CBT
– T1 vs. T2 3.030 7 0.019
Self-esteem 2.874 6 0.123
– T1 vs. T3 3.936 6 0.0170
Dermatology quality of life 2.048 6 0.122
– T1 vs. T4 2.862 5 0.024
Body image feelings 0.967 6 0.475
Person-centred
Positive thoughts 1.561 6 0.226
– T1 vs. T2 1.818 8 0.107
Negative thoughts 2.232 6 0.097
– T1 vs. T3 2.580 7 0.036
Perceived stress 1.676 6 0.195
– T1 vs. T4 4.703 6 0.042
General health 3.020 6 0.039*

* = Significant.

Photograph Analyses: Physiological Change


Table 5. One-way ANOVA results for general health for each group
A multiple analysis of variance with time point as the repeat-
F df p ed measures factor and experimental group as the indepen-
dent factor showed that there were no overall improvements
CBT 8.553 3 0.014 in pigmentation over time for any of the experimental groups
Control 0.899 3 0.534
(F = 1.379, df = 4, p = 0.321) (table 7).
Person-centred therapy 7.344 3 0.020

Discussion
Design
The study used a 3 × 4 mixed factorial design for the questionnaire analy- Following on from the recent finding that individual CBT was
sis. The independent factor was the experimental condition; control, CBT effective for vitiligo in the context of psychological and social
and person-centred therapy, and the repeated measures factor was assess-
ment point; pre-treatment (T1), post-treatment (T2), 6-month follow-up
adjustment [Papadopoulos et al., personal data], group CBT
(T3) and 12-month follow-up (T4). The study further used a 3 × 3 mixed was compared to group person-centred therapy trials. Results
factorial design for photograph analysis. The independent factor was the have shown that the groups of vitiligo patients who undertook
experimental condition; control, CBT and person-centred therapy, and the 8 consecutive sessions of group CBT showed no signifi-
the repeated measures factor was assessment point; pre-therapy (T1),
cant improvement in all of the psychosocial variables used in
6-month follow-up (T3) and 12-month follow-up (T4). No immediate
post-treatment assessment was taken for the vitiligo pigmentation as it
test with the exception of general health. This included posi-
was expected that there would be a delay before any changes in pigmen- tive and negative thoughts, body image feelings, perceived
tation would be realised. stress, self-esteem and quality of life. No gains were shown at
6-month and 12-month follow-up. The participants in the per-
son-centred therapy paradigm also showed prolonged im-
Results provement in general health but not in any other psychosocial
variable. Unlike the group CBT results, there was a delay in
Multivariate analyses of variance were judged inappropriate general health improvement. The improvement was not
due to the theoretical diversity of the dependent variables. A shown immediately after therapy but at 6 months. This sup-
multiple analysis of variance was carried out for each depen- ports previous work [Bergin and Garfield, 1994] that has
dent variable and the interaction between the between-partic- found a delay in gains made due to person-centred therapy.
ipants variable (experimental group) and the within-partici- The intensity, direction and structure of CBT may lend itself
pants variable (time point) was not significant. to more immediate gains in general health whereas changes
Tables 4, 5 shows that the CBT and person-centred groups made in the person-centred process may take longer to realise,
made significant improvements only in general health. For the post-therapy. Further work might explore this disparity. Final-
CBT groups, improvements were noticeable directly post- ly, individuals in the control group showed no improvement in
treatment and maintained over the duration of the follow-ups. any of the psychological and social instruments used in the
For the person-centred groups, improvements were only visi- protocol. It is possible that the reason for the effective change
ble at 6-month and 12-month follow-up but no improvement in general health for both CBT and person-centred groups
was found immediately after therapy (table 6). There were no concerns the GHQ emphasis on the recording of anxiety and
significant changes in the responses obtained from the control depression. It may be that the group therapies are able to ad-
group on any of the above variables at any time point. dress generalised anxiety and depression in clients’ lives with-
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Table 7. Mean vitiligo spread (%) and standard
deviation for the three experimental groups T1 T3 T4


over the 3 time points mean SD mean SD mean SD

Control 13.857 13.520 12.246 12.976 14.109 15.330


CBT 18.348 15.334 17.856 16.490 19.232 14.911
Person-centred 9.905 10.718 10.247 13.691 12.823 15.267

out particularly addressing issues that pertain to their skin time and resources that simply may not be an option in a
condition. group format.
It was considered that group person-centred therapy might There were no significant physiological benefits produced by
have succeeded where individual person-centred therapy pre- either experimental group. As with earlier work [Papadopou-
viously failed [Papadopoulos et al., personal data] because al- los et al., personal data], there was significant and tangible im-
though person-centred therapy is client-led, the fact that the provement in some participants in all three experimental
group was brought together under the auspice of vitiligo may groups. However, the differences did not extend to between-
have tended to focus the group in the direction of their skin group significance. Since the group therapies failed to signifi-
disease and so more time may have been spent addressing this. cantly benefit participants psychosocially, it was perhaps not
In light of the results, this may not have been the case. Fur- surprising that there was no physical improvement either. We
thermore, group person-centred therapy would have allowed are forced to reason that so little is still known about the phys-
participants to benefit from the experience, advice, comfort iological basis of vitiligo and the relationship between the psy-
and understanding of others in a similar position to their chosocial and physiological aspects of stress that a great deal
own. This is obviously not an option for individual therapy of further research is required before we are able to make de-
and while this may have been the case, the effect was not suffi- finitive conclusions concerning psychological therapy and dis-
cient to improve the participants’ scores on the dependent ease physiology.
variables. Richards et al. [2001] showed that only 10% of dermatology
It would appear that group CBT is an ineffective intervention patients would be interested in taking part in a programme
for vitiligo participants. There could have been a number of offering psychological assistance and this could have obvious
reasons for this. One crucial point to be made and a defining implications for the success or failure of the therapy trials.
difference between the individual and group therapy is that of Working with a self-selecting sample, however, is always a
the assessment process. Only a group assessment process difficulty encountered in psychotherapy research and the
could be used, which did not allow the therapist to obtain the wide range of recruitment sources attempted to ameliorate
same individual knowledge of the clients’ psychological and this issue. Another aspect of undertaking therapy trials is
social conceptualisation of their disease and its ramifications. that the compliance of each individual to treatment will
As such, it would make it difficult for the therapist to establish vary and this is especially relevant since CBT involves home-
commonality in the first session. work that is carried out away from the group. The cultural
In many ways this problem is not only limited to the assess- generalisability of this project is questionable since it was
ment session. To work with 8 participants in an 8-week period carried out only in London and only using English speakers.
and with a detailed protocol can limit the therapist when at- Future research could test this protocol with different cul-
tempting to explore, assess and modify issues that can be idio- tural samples.
syncratic to the experience of a particular participant. Partici- With respect to the photographic analysis, the procedure is an
pants come to therapy with a lifetime of experiences that have effective measure of body area but there are always problems
shaped and been shaped by the schematic conceptions that associated with using a two-dimensional photograph as a rep-
they have of their own self-worth, their body image and their resentation of a three-dimensional body. One problem with
adjustment to the challenges of their disease. While one par- the procedure concerned the fact that it may not have been
ticipant may experience sexual problems due to a lack of com- sufficiently subtle to detect minor but significant changes in vi-
munication with their partner regarding feelings of embarrass- tiligo pigmentation. Future work should strive to create a
ment and shame around their skin, another participant may more detailed and accurate procedure.
have developed an aversion to exposing their skin in public
places as a result of constant skin-related bullying and teasing
that they received when they were an adolescent. The very Acknowledgements
fact that individual CBT was successful in earlier work was
likely due to the fact that it addresses deep-rooted schematic The authors would like to thank The UK Vitiligo Society for their support
conceptions of the self. To do this within therapy can require with this research.
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