By Center for Change
Struggles with body image have a long reach. One study found that as many as 50% of young women in the United States are highly dissatisfied with their bodies and this dissatisfaction, if left untreated, may endure throughout the life span. Body image disturbances can be particularly challenging to treat in the clinical population of women and girls struggling with eating disorders. Even in non-clinical populations, body image struggles can be pervasive–fueled by a culture that is obsessed with dieting, the thin-ideal, and is generally fat-phobic.
Very few seem to escape the effects of a culture obsessed with perfection, beauty, and thinness. In fact, it is so commonplace for women to experience shame and dissatisfaction about their physical appearance that researchers have called this concern about body weight “normative discontent” (Rodin, Silberstein, and Striegel-Moore, 1985). Unfavorable thoughts, feelings and attitudes toward body weight and shape plague young girls and women irrespective of age, race, sexual orientation, or gender identity.
Yet, even with the commonality of this struggle, the notion of body image is often elusive and mysterious. It is a subtle experience and yet at the same time, overpowering for those struggling with negative thoughts and feelings about their body.
As clinicians working with individuals diagnosed with eating disorders, we are all too familiar with the ways in which our patients become entrenched in shame about their body, overall appearance, and how this is deeply connected with felt shame about who they are at their very core. Body image becomes intertwined with identity. Body image disturbance is both a crucial developmental risk factor as well as a core feature of the clinical population of individuals diagnosed with an eating disorder. Behaviors may improve, yet perception of one’s body as defective and flawed may continue. Negative body image is one of the last clinical features to remit during the recovery process. Left untreated, body image is also a predictor of relapse for those in recovery. Delivering effective interventions for body image is an important part of the clinical work of helping people move into and sustain recovery.
Toward a Deeper Understanding of Body Image
What are we talking about when we use the term “body image”?
At the most basic level, body image can be defined as the mental picture one has of their own body. It includes a more global and emotional feeling and experience of one’s body, both in a specific moment and in an all-encompassing and enduring way. There is really nothing simple or basic about body image. It is about so much more than loving or hating, or even accepting, one’s body or body parts.
One of the first to write about body image in the 1920’s and 30’s, neurologist and psychoanalyst Paul Schilder introduced the idea that the image of the human body is a continually changing sensory and tactile picture of our own body which we form in our mind. He included a multi-faceted approach to body image that included the physical, sociological, and psychological. For example, when we experience hate or fear, our bodies become firmer with stronger boundaries toward the outside world. In contrast, when we experience friendly and loving emotions we expand with open arms and those strong boundaries become less defined and more permeable as we connect with the body of another person.
The construct of body image is complicated and multi-faceted, but above all else it is a lived experience. Body image is an experience that may or may not be congruent with the outer physical reality. It can include how we think and feel about our age, ethnicity, strength, sexuality, gender identity, and appearance. Our bodies are so often a site of social, political, cultural, and intrapsychic struggle. The way we feel about our bodies is often closely related to how we feel about ourselves.
Persons who are body self-conscious may be compelled to spend extraordinary amounts of time thinking about how they feel about their bodies and engaging in behaviors to alleviate distressing emotions. The body becomes an object of hate- something to ignore, deny, or extensively manage in an attempt to moderate self-contempt and feelings of inadequacy.
Healthy or stable body images are flexible and fluid, changing and becoming more or less important throughout the course of a lifetime. Unstable body images, for example, may experience changes that are less fluid and more abrupt and painful, characterized by hostility toward one’s body. This hostility turned inward may be based on mood, relational interactions, or food consumption. In an individual struggling with an unstable or rigid body image there exists a preoccupation and painful self-consciousness. Yet, even with a single-mindedness on perceived image of the body, there lies at the core, a fundamental disconnection from the lived experience of the body.
Body Image as Self Worth Measure
From birth we are developing a sense of self which includes a complex and multi-sensory body-self. Our body has been referred to in the literature as our most fundamental sense of ourselves, especially during the developmental years of childhood. Think for a moment about a baby discovering his hands and feet. This is an amazing part of human development- our sense of self is an experience, an embodiment, it is lived.
It is possible that the body can be a place of comfort, confidence, acceptance, and aliveness; however, for those suffering with an eating disorder and others with negative body image, it is most often a place of anxiety, shame, and discontent.
Our clients are suffering from a disorder of the self that includes the body self. Researchers suggest that early developmental arrests in establishing a coherent and stable body image can result in a maladaptive body image. When a person lacks an internal stable image of themselves, various distorted attempts are made to create, control, manage or modify an external image. The prevailing thin ideals of our media driven culture, being female, adverse childhood experiences, and an underdeveloped sense of self are contributors to the development of negative body images.
Objectification theory tells us that when women are frequently sexually objectified and viewed as simply a physical body, their worth and value becomes tied to their appearance and how closely they meet culture-bound beauty ideals. It is understood that over time, repeated objectification leads to adopting an observers’ perspective and beginning to treat their own bodies as something separate to be looked at and judged based on appearance. This self-objectification leads young girls and women down a path of body shame, body anxiety, and behavioral attempts to manage their bodies to both meet the internalized ideal and avoid judgement from others and the associated pain that comes from feeling judged for having fallen short.
Additionally, in sexual objectification, the objectified person can begin to believe their body is really not their own, but must be what others want it to be for self-centered or selfish desires.
Although not everyone internalizes messages in the same way, studies have found that those with a lower sense of self-worth and self-esteem are more prone to internalizing messages received from the culture or media about their bodies and the importance of the thin-ideal.
Life Cycle Considerations
Currently most body image programs and research have been targeted to a younger female audience; however, women of all ages are struggling with negative feelings about their physical appearance and experience body shame regardless of age. . One study found that women 18-59 reported a desire to be significantly thinner than their current body shape.
Through all stages of life women experience more body, weight, and physical appearance concerns than men. Women experience more significant changes in their body through pregnancy, childbirth, and menopause. Research results indicate that women in the aging process may be more vulnerable to disordered eating behaviors in an attempt to prevent the changes that are happening in their bodies related to growing older in a culture where youth is valued and equated with beauty.
There are some protective factors as women grow older; such as acceptance of body changes; however, it remains a salient issue for women regardless of age. Studies have shown that the impact body image may have on self-esteem may lessen over time and there may be a greater tolerance for variance in acceptable body size, although tolerance of a variety of body shapes in others does not necessarily indicate tolerance or acceptance of one’s own body shape and size.
In the Therapy Room
The space between what one thinks they “should” be and their perception of what they “actually” are is the therapeutic residence of clinicians working with girls and women with eating disorder and body image dissatisfaction and disturbance. Our patients come to us feeling that they have fallen short of an ideal or goal accompanied by dislike, dissatisfaction, or disturbance of their body images. They may describe this as falling short in relationships, in their ideal body weight and shape and in life accomplishments. More severely, we may hear them tell the narrative of having fallen short well beyond social standards for beauty, but in being a human of value in the world.
Body image disturbance goes beyond how one sees and experiences their body to how one sees and experiences themselves as a person. We notice our clients’ body images becoming increasingly rigid around an ideal image and see the subsequent result that cuts them off from really living in an embodied way. Girls are socialized at a young age to confuse body esteem with self-esteem. Their self-worth is subverted as body-esteem and begins to rule their interior sense of self, leading to maladaptive and dangerous behaviors in the exterior. This is fertile ground for the development of a clinical problem between inner and outer/internal and external.
Eating problems and body image dissatisfaction rob our clients of the full expression of emotions in their life: joy, excitement, sadness and grief for example. The struggle of living in the perceived discrepancy between actual and ideal can generate a profound sense of shame and anxiety about one’s value and place in the world. A low sense of self-worth and value in the world can then become “concretized” or solidified in the external world in the form of body image disturbance and disordered eating symptoms.
It is not necessarily a negative thing that body image is intertwined and linked with sense of self. This is important because developmentally, the body is a key aspect of who we are as humans. The clinical work is about building up the sense of self. Clinical work must include the body in the healing process.
Just as body image itself is multi-faceted and involves the whole person, so our treatment must also be a multi-layered reflection that will engage the person we are treating at the level of body, mind, and soul.
We must remember as a foundation for treatment that we are treating a person, not an illness, not symptoms, but the individual as a whole: physical, mental, emotional, sexual, and spiritual.
Body image disturbance is a core symptom and lived experience for clients presenting with an eating disorder. It is often present before the active symptoms began, related to an unstable or unintegrated sense of self, and may be present after eating disorder behaviors subside, with the work of healing one’s body image continuing long into the recovery process. It is well-established in the literature that body image is complex construct that is initiated at birth and influenced by developmental experiences and the socio-cultural landscape. The physical body is the container in which our psychological and spiritual self resides and interacts with the world.
Media literacy, consumer awareness, and becoming a critical viewer of messages about body in our culture are important, for those with severe eating disorders. We also know that the therapeutic work must go well beyond that to a focus on deeper themes. Body image is a perceptual, cognitive, emotional, and physical experience that undergoes continual transformation throughout the lifespan. Treatment must then follow suit and include an integrated approach where clinicians are including both the external physical experience as well as the internal subjective experience of being in and having a body and the ways in which this is intertwined with self-worth.
Our patients’ concerns about body image are so often connected to how they feel about themselves. As eating disorder clinicians, we recognize the life limiting impact of extreme dietary restraint, body surveillance, appearance fixing or avoiding, hiding the body, body checking, weighing, measuring and other compensatory behaviors. We also recognize the negative impact of the sense of self as “unworthy”, “not good enough”, or “not enough” which demands a lion’s share of the work of recovery.
In addition, it is also important that we have a deep understanding of the intensity of shame involved in these behaviors. A shame-based illness will lead a person to do just about anything to stop feeling that level of pain and suffering that comes from unrelenting self-rejection.
Relationships suffer as social lives becomes increasingly narrow to avoid the judging gaze of another human, all the while suffering their own internal judgement.
The treatment of body image is inherently the treatment of a low sense of (bodily) self-worth, (body) shame, (body) anxiety and one’s sense of (their body’s) diminished value in the world and the external and internal manifestations of these struggles.
Working toward the healing of fractured body images is the therapeutic work of developing a sense of self. Much of our clinical work targeting body image disturbance and related symptoms includes working with shame and shame resilience.
It is common that individuals with eating disorders avoid turning toward their inner world and getting to know their own needs, wants, desires, and emotions. To connect with themselves in this way brings to the surface the deep sense of shame that is felt at a body-soul level. However, to heal, this connection with their own sense of self and sense of connection with something spiritual that is bigger, deeper, or beyond is essential. The road to recovery includes honoring their experience and taking up space in the world physically, psychically, relationally, and spiritually. Indeed, the recovery process if one of a reclamation of identity or finding one’s self and one’s sense of value again.
A Comprehensive Plan
The following are considerations for the development of a comprehensive plan of care for working with those with body image struggles. This is not necessarily a strict linear process, but more a layered flow where each element interacts with the others and clinical wisdom and collaboration with each patient guides the work.
Assessment: We start with asking good detailed questions about the history and duration of the body image disturbance and use applicable assessment measures (http://www.body-images.com/assessments/). We want to have a deep understanding of the specifics of each patients’ negative body image and how it impacts their life on a daily basis. Then in addition, we observe both verbal and nonverbal responses to our therapeutic inquiry. Since both the body and images are nonverbal, it is essential to watch and listen for the nonverbal communication of our patients. What and how is their body communicating? How do they walk into and out of the room? What gestures do they use? How do they sit and position themselves? How do these gestures or movements connect with the verbal responses to the questions?
We also want to do a thorough assessment of their sense of identity, sense of self, and sense of spiritual identity. Questions which illuminate how they feel about themselves, what they think about “who they are” and their sense of worth are also critical to ask.
Case Formulation and Conceptualization: From a thorough assessment process we can begin, with the help of our patients, to draw our conceptualizations of the unique experience of each patient. We explore how the basic ideas around their body image and physical appearance came to be and then we continue moving the work deeper toward an understanding of how each patient makes meaning of these life experiences. We explore both historical and current factors in order to come to a deeper understanding of the ways in which they are embodied or disembodied. This process establishes a framework for the cognitive, emotional, behavioral, and spiritual interventions. We do the same with the sense of self-image so we can begin to have a conceptualization of how they came to think and feel about themselves the way they do.
Treatment Planning: This involves determining the approach, interventions, and format of delivery of care. Often the treatment for body image is integrated into the bigger plan for treatment for eating disorder symptoms and behaviors. There is overlap in the recovery work as approaches such as CBT, DBT, ACT, and ERP are integrated to comprehensively treat this complicated illness. This may include:
- Psychoeducation on the interplay of emotions, thoughts, body sensations, and behaviors
- Practical skills training on managing the complexity of the human experience and suffering (distress tolerance)
- Experiential, somatic and creative arts that offers direct access to the body and the inner and outer experience.
- Movement work that explores joyful and mindful movement that one enjoys such as yoga, dance therapy, or walks in nature.
- Exposure to feared or avoided stimuli
- Perceptual and cognitive interventions
- Discovery of self and spiritual identity
It is important to note that patients often need to start by working on tolerating the distress around the negative feelings they have about their body before they can move into a place of acceptance, gratitude, self-compassion, loving-kindness, and celebration of all the parts of who they are.
How We Help
When patients are struggling with a lack of a coherent and stable sense of self, it can be hard to trust that a relationship can be reliable. The therapeutic relationship is an essential and key part of this healing process. A key aspect of the development of trust is found in honoring the role the symptomatic behavior has played for the patient. In the case of body image disturbance, it may be that behaviors either make them feel alive or bring a sense of calmness to the interior feeling of chaos and instability. The behaviors make sense when we are able, as therapists, to get into the feeling space of the patient and deeply understand their emotional experience. What may look irrational and pathological on the outside, may make great sense when we listen deeply and get into the soup with our patients and deeply engage in the relationship. We help by being human ourselves and engaging them at the level of their humanity beyond the symptoms.
As therapists we can help with:
- Developing an internal sense of self such that the external body-self does not hold all of the responsibility for aliveness, but that it can be a shared experience. Aliveness can be both felt internally and experienced externally through one’s body interacting with the world.
- Cultivating a clearer sense of self and identity apart from body image
- Healing the split between inner and outer to create an integrated sense of self
- Growing into a respectful relationship to their body and accepting no less from others
- Shifting focus from image to focus on experience of having a body
- Moving from body hate to neutrality and then to full acceptance of what it means to have a body with the ups, downs, and changes that occur over a lifetime.
- Untangling the web of perfectionism and idealism which sees the body as a machine to be controlled and managed in service of truly living in the body engaged in creative expression and enjoyment of all foods.
- Finding value, meaning, and purpose in their lives and the ways in which that lived life has marked the body (scars, stretch marks, wrinkles, hair growth or loss etc..)
- Holding space for spiritual exploration and development of a spiritual identity
- Living an example as a therapist who embodies an attitude of body acceptance and self-esteem
Some Key Treatment Focus Areas for Body Image Healing
Separation of self-esteem and body esteem
Self-esteem and body esteem often times become conflated in the individual with an eating disorder. The critical inner voice and stories our patients tell themselves about their unworthiness and unlovability is at the core of body hatred. Helping our patients develop a sense of self-worth and value in the world separate from the shape, size, or weight of their body is an essential aspect of healing and recovery. A coherent and stable sense of self and identity is a key element in healing a wounded body image.
Working with Shame through Self-Compassion and Loving Kindness
It is common to hear patients report high levels of shame about their bodies as they make efforts to disembody, disconnect, and create distance to combat the intensity of that feeling. The shame and anxiety associated with a disrupted sense of self and body hatred are unrelenting for our patients. Both research and clinical wisdom reveal that the antidote to shame is self-compassion. Self-compassion is spiritual practice and orientation to suffering that allows the patient to work with difficult and challenging material with an attitude of loving kindness toward themselves. Introducing our patients to the courageous work and their inherent goodness and compassion is an essential part of healing from the shame of self and body.
Focus on Relationships
Relationships to self, body and others are deeply impacted when someone is suffering from an eating disorder and body image disturbance. Isolation becomes a coping mechanism and life is measured by comparison to others. Relatedness is a healing balm and helps distressing emotional experiences become more tolerable. Relating to others, for example, in the group format in a treatment setting helps reduce isolation and build connection and understanding.
Relating to the body begins not by moving directly toward unconditional love and acceptance of one’s body, but rather by learning to tolerate the distressing feelings one has about one’s body. Skills such as self-soothing and gratitude start to change the relationship to one’s body opening up possibility for acceptance, gratitude, and interacting with the body with self-compassion and loving kindness.
Integration of Meaningful and Life-Enhancing Activities
Healing a painful relationship with one’s body and embracing embodiment is difficult work. As clinicians we can offer our patients the opportunity to explore their own personal meaning and purpose in life beyond body hatred. We provide opportunities for our patients to explore their values, spiritual path, relationships, and passions. We explore purpose and how our patients can contribute something meaningful to their communities in order to live a life of deep meaning and connection.
It is important to recognize that body image disturbance is about more than “I hate my body”. For many girls and women suffering from an eating disorder it goes deeper to “I hate myself”. The healing work then includes targeted body image work as well as development of self-worth and the spiritual principles of self-compassion and loving kindness while integrating life-enhancing and purpose-filled activities.
(Note: While we also see these issues in boys and men, this article has focused mainly on the female experience, acknowledging that some of the interventions may be implemented regardless of gender. In addition, much of the research and data on body image and eating disorders has been gathered from predominately White, adolescent and young adult women. It is important to note that research and resulting clinical interventions are needed for different cultural groups.)
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