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Overcoming
body
image
disturbance

A Programme for People

with Eating Disorders

LORRAINE BELL AND

JENNY RUSHFORTH
First published 2008 by Routledge
27 Church Road, Hove, East Sussex BN3 2FA

Simultaneously published in the USA and Canada

by Routledge
270 Madison Avenue, New York, NY 10016

This edition published in the Taylor & Francis e-Library, 2008.

“To purchase your own copy of this or any of Taylor & Francis or Routledge’s
collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.”

Routledge is an imprint of the Taylor & Francis Group, an Informa business

Ø 2008 Lorraine Bell and Jenny Rushforth

All rights reserved. No part of this book may be reprinted or reproduced

or utilised in any form or by any electronic, mechanical, or other means,
now known or hereafter invented, including photocopying and
recording, or in any information storage or retrieval system, without
permission in writing from the publishers.

This publication has been produced with paper manufactured to strict

environmental standards and with pulp derived from sustainable forests.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging-in-Publication Data

Bell, Lorraine, 1956±
Overcoming body image disturbance : a programme for people with
eating disorders / Lorraine Bell and Jenny Rushforth.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-415-42330-4 (pbk.)
1. Body image disturbance±Treatment. 2. Eating disorders±Treatment.
I. Rushforth, Jenny. II. Title.
[DNLM: 1. Eating Disorders±therapy. 2. Body Image. WM 175 B434o
2008]

RC569.5.B65B45 2008
616.85©2606±dc22
2007031819

ISBN 0-203-93199-8 Master e-book ISBN

ISBN 978-0-415-42330-4 (Print Edition)

 Contents

Introduction viii
Acknowledgements ix

1. Body image and body image disturbance 1

What is body image? 1

Concern about appearance 2
What do we call body image problems? 2
How body image disturbance develops 3
Trauma, childhood abuse and body image 8
What reduces the risk of developing body image disturbance? 10

2. Body image disturbance and psychological

disorders 16

Body image and eating disorders 16

Body Dysmorphic Disorder 18

3. What works? The design of this programme 24

Research evidence for improving body image 24

What an effective body image programme needs to address 24
Rationale for this programme 27
Outline of this programme 29
Aids to assessment and outcome measurement 30
vi Contents

4. Therapist skills needed for this programme 35

Assumptions and tenets 35

Prioritising tasks in session 35
Collaborative working 37
Guided discovery and socratic questioning 38
Mindfulness and the three Cs 39
Maintaining a therapeutic alliance 39
Using similes, analogies, metaphors and stories 41
Balancing acceptance and change 43
Validation 44
Dialectical and commitment strategies 44
Setting homework tasks 47

5. The programme 49

Programme timetable 49
Session 1: Assessment 50
Session 2: Discussion of psychometric scores and personalised
formulation 55
Session 3: Mindfulness 1 57
Session 4: Mindfulness 2 62
Session 5: Changing unhelpful habits 64
Session 6: Non-judgemental stance 68
Session 7: The media 71
Session 8: Preparation for exposure 74
Session 9: Mirror exposure 1 77
Session 10: Mirror exposure 2 80
Session 11: Review, consolidating change and troubleshooting 82
 Contents vii

Optional additional work on `Self-worth and body

image investment' 84
Optional additional work on `Compassion' 86
Session 12: Continuation plan 89
Review at 6 weeks 91

Appendix 1: A psycho-biosocial model of body image

disturbance and eating disorders 93
Appendix 2: How I feel about my body (Body Image
Continuum Scale) 94
Appendix 3: Handouts 95
Appendix 4: Template for farewell letter 136
Appendix 5: Scoring instructions and norms for body
image measures 137

Index 145
 Introduction

This programme has been developed as part of a range of services provided

by the Eating Disorders Team for Portsmouth and South East Hampshire
for people over 16 years of age. A pilot of the programme has been evalu-
ated using a case series of six patients who had recently received treatment
in the service for Anorexia Nervosa, Bulimia Nervosa or Eating Disorder
Not Otherwise Speci®ed. After 12 sessions, these patients showed statistical
and clinical change across a range of measures including the Rosenberg
Self Esteem Scale, the Body Attitudes Questionnaire, the Body Dissatisfac-
tion subscale of the Eating Disorders Inventory-2 and the Bodily Shame
subscale of the Experience of Shame Scale.
The programme is intended to be used with close guidance from a
therapist (preferably one experienced in the treatment of eating dis-
orders), although if someone was well motivated they could follow the
programme independently. With this in mind, the book has been written
for both clients and therapists. Chapter 1 introduces the concept of body
image and body image disturbance. Chapter 2 addresses body image dis-
turbance and the psychological disorders associated with it, in particular
eating disorders and body dysmorphic disorder. Chapter 3 reviews the
evidence for the treatment of body image disturbance and the theoretical
basis for the design of this programme. Chapter 4 outlines the main skills
that therapists will need when delivering the programme. Chapter 5 gives
detailed notes for therapists in how to conduct the programme.
As much information as possible is given, including recommended
psychometric measures to aid assessment and evaluation of outcome. The
measures themselves are not included as it was not possible to obtain
permission for all the measures we recommend.
 Acknowledgements

We would like to thank our colleagues Amanda Jones and Lisa Butler for
their proof-reading and invaluable suggestions. We would also like to
thank all our eating disordered clients from whom we have learned so
much and whose courage and persistence in their recovery is an inspira-
tion to us. We would like to express our appreciation to senior clinicians
and academics in the ®eld of eating disorders, in particular Janet Treasure,
Kelly Vitousek and Josie Geller, who continue to provide leadership in the
development of high-quality services for people with an eating disorder.

Lorraine Bell and Jenny Rushforth

February 2007
 Online resources

The appendix of this book contains worksheets that can be downloaded

free of charge to purchasers of the print version. Please visit the website
www.routledgementalhealth.com/overcoming-body-image-disturbance to
®nd out more about this facility.
 1

Body image and body image disturbance

WHAT IS BODY IMAGE?

An early de®nition of body image states

The picture of our own body which we form in our mind, i.e. the way in which the body
appears to ourselves.
Schilder (1935)

In addition to our perception of our body, including evaluation of our size,

there is an emotional or attitudinal aspect to our image of, or evaluation
of, our bodies, i.e. the way we feel about our body. This is the aspect on
which we usually focus when we talk about negative body image in
people with eating disorders, using the terms body dissatisfaction or dis-
paragement. Slade (1988) describes the perceptual and the attitudinal
aspects in his de®nition:

The picture we have in our minds of the size, shape and form of our bodies and our
feelings concerning characteristics and constituent body parts.

More recent psychologists have added a third component ± our behaviour.

Hence, Rosen (1995: 369) de®nes body image as

a person's mental image and evaluation . . . of appearance and the in¯uence of these
perceptions and attitudes on behavior.

Thomas Cash (Cash and Deagle 1997; Cash and Pruzinsky 2002) distin-
guishes an evaluative component and investment component (the import-
ance or salience of one's appearance). Evaluation refers to the satisfaction
or dissatisfaction with one's body and beliefs about one's appearance.
Investment refers to the importance placed by the person on their
appearance.
In summary, therefore, a negative body image usually has the following
components:
2 Overcoming body image disturbance

perceptual distortion;
failure to meet unrealistic size and weight goals leading to body dissatisfaction and
negative mood;
investment in appearance as the central criterion of self-evaluation resulting in selective
attending to appearance messages;
behaviour, such as the pursuit of thinness through dieting or other weight loss
measures.

CONCERN ABOUT APPEARANCE

The preference for attractiveness is universal. Body `grooming' to enhance
one's appearance (with clothing, cosmetics, hair styling, jewellery, body
art, etc.) gives people pleasure and pride in their physical appearance and is
common across all cultures. Wanting to be attractive makes good sense, as
being attractive confers many evolutionary and social advantages. There is
considerable evidence that attractive children and adults are treated more
favourably and experience a wide range of bene®ts, although most of this
research has been carried out on facial attractiveness. However, to the
extent that cultural messages about physical attractiveness are `inter-
nalised' and serve as personal ideals, they may adversely affect our evalu-
ation of and satisfaction with our physical appearance. Physically attractive
people are not necessarily satis®ed with their appearance, nor are less
attractive people inevitably unhappy with their looks. It is a person's
perceptions, beliefs and feelings about their appearance that are more likely
to determine their body image than their actual physical characteristics.
Body image dissatisfaction can have devastating effects on psychologi-
cal and physical health. Negative body image and over-concern with
shape and weight are cardinal features of eating disorders, although not
for everyone with an eating disorder. Body image disturbance or negative
body image is not unique to eating disorders. It is also found in
neuropsychological disorders, `delusional disorder' and body dysmorphic
disorder (BDD). BDD will be discussed below.

WHAT DO WE CALL BODY IMAGE PROBLEMS?

There are a range of terms used in the academic literature for body image
problems, but they are unclear and poorly de®ned. A negative body image
(i.e. discontent with or negative evaluation of some aspect of one's
physical appearance) can range from mild feelings of unattractiveness
to extreme obsession with physical appearance that impairs normal
 Body image and body image disturbance 3

functioning. Body dissatisfaction is the result of a discrepancy between

perceived and ideal self. Body dissatisfaction has become so widespread
among women that it is now considered the norm. Rodin et al. (1984)
coined the term `normative discontent'. The problem with the term body
dissatisfaction is that it does not take account of the impact this has for an
individual in terms of personal distress or levels of functioning. Body
image can be seen on a continuum from positive to acceptance to negative,
but it is also important to identify the degree of investment in or salience
to the individual's self-worth or self-evaluation.
The thoughts associated with a negative body image may be described
as `obsessional', i.e. repetitive and intrusive, or `delusional', i.e. distortions
of reality held with complete conviction. `Overvalued ideas or beliefs'
may be a more helpful term. It falls somewhere between the two in terms
of insight in that, although it is entrenched, the client may acknowledge
that it isn't necessarily true (Rosen 1997).
Gilbert and Miles (2002) propose the concept of body shame resulting
from parental criticism, peer teasing or sexual abuse. Across samples, body
shame is consistently related to higher body `surveillance', lower body
satisfaction, lower psychological well-being and more eating problems.
Thompson (1992) proposed the concept of body image disorder, i.e. a
persistent report of dissatisfaction, concern and distress that is related to
an aspect of appearance. Some degree of impairment in social relations,
social activities or occupational functioning must be present. He further
proposed that severity be coded from mild to severe, and that the physical
focus of the concern, and how `objective' the body image complaint is, be
speci®ed (from `valid' to `delusional'). As this is neither widely used, nor a
formal diagnosis, we will use the terms body image distress or body image
disturbance.

HOW BODY IMAGE DISTURBANCE DEVELOPS

Culture

The most powerful in¯uence on body image is culture (McCarthy 1990).

The mass media (fashion magazines, television advertisements and shows,
and motion pictures) present `a constant barrage of idealised images of
extremely thin women' (Nemeroff et al. 1994). This promotes the `glori-
®cation of thinness' (Gilbert and Thompson 1996) by equating it with
attractiveness, happiness, status and success, while at the same time
linking fatness with such negative connotations as laziness, ugliness and
4 Overcoming body image disturbance

failure (Rothblum 1994). Thus, appearance and, in particular, shape and

weight become central to women's self-evaluation and self-worth. This is
likely to have particular in¯uence in adolescence, when the major devel-
opmental task is the establishment of identity.
Accumulating research demonstrates links between sociocultural
pressures fostering internalisation of the thin ideal and body dissatisfac-
tion or body image distortion (Groesz et al. 2002; Polivy and Herman
2002). Experimental studies show how exposure to thin media images and
interpersonal pressure to be thin increases body dissatisfaction (e.g.
Hawkins et al. 2004; Turner et al. 1997). Further, a number of studies have
found a direct link between media exposure and eating disorder attitudes
and behaviours (Hawkins et al. 2004; Stice et al. 1994; Thomsen et al.
2001).
Body image disturbance is higher in western white or Caucasian women
(Altabe 1998), but due to globalisation, individuals in non-western cul-
tures are increasingly exposed to western ideals. A range of studies has
identi®ed increased incidence of eating disorders with westernisation.
The powerful negative effects of western media in¯uences were demon-
strated in a study by Becker et al. (2002). Rates of dieting, body image
disturbance and eating disorders were identi®ed in matched samples of 65
17-year-olds before and after the introduction of TV in Fiji. There were no
eating disorders in 1995. In 1998, 69 per cent of girls had dieted, 74 per
cent felt that they were too fat and 11 per cent induced vomiting to
control their weight (0 per cent in 1995). The negative psychological
impact of western culture is not speci®c to eating disorders. Rates of
mental illness or psychological disorders in general are higher in more
af¯uent countries (James 2007).

The myth of transformation

The pursuit of thinness is imbued with the `myth of personal trans-

formation'. Increasingly drastic means of modifying one's body are now
presented as normal, including the use of cosmetic surgery. The media
promote the belief that we can control our appearance if we try hard
enough. However, there is a natural diversity in body size and shape,
which is signi®cantly genetically in¯uenced. Further, the standard of
thinness now is impossible for the great majority of women to achieve by
healthy means (Wolf 1991). The images now presented may not be
attainable or only attainable by a minority via extreme behaviours (Hsu
1989; Thompson et al. 1999). The ideal female ®gure became thinner in
the last 30 years while people got larger (Wiseman et al. 1992) and rates of
 Body image and body image disturbance 5

obesity rose. Several cultural changes make it increasingly dif®cult to

maintain a low weight, such as the increase in sedentary leisure activities
and the rise not only in fast food consumption but also in size of food
portions. However, many women believe that, with enough effort, they
can control their body weight and shape to achieve this ideal (McKinley
2002) and that it will bring them success in most areas of their life
(Mussel et al. 2002).

Who's vulnerable?

Brief exposure to media images of thin female models from magazines has
been shown to produce a range of immediate negative effects, including
greater concern about weight, body dissatisfaction and negative mood.
However, this impacts more on some individuals than on others. Numer-
ous studies have indicated that those who already have body dissatisfaction
are vulnerable (e.g. King et al. 2000; Polivy and Herman 2004; Stice 2001),
as are people who have eating disorders (Pinhas et al. 1999) or are over-
weight (Henderson-King and Henderson-King 1997). Posavac and Posavac
(2002) found these in¯uences to be independent of global self-esteem.
Research shows that women and girls who are most dissatis®ed with, or
have invested in, their appearance seek out particular media content.
People for whom appearance is critical to their self-concept selectively
attend to the appearance-related aspects of any presented material. Their
feelings and beliefs about their body image are then `activated' by media
images. Those who already invest most in their appearance are more
vulnerable to the effects of idealised media images and become caught in
a downward spiral in which negative body image is exacerbated by further
exposure to such images. Conversely, women with low investment in
their appearance are `protected' from the negative psychological impact of
these images.
Hence, body image treatments need to help people to change both the
degree of their personal investment in their appearance and their selective
attentional bias and, in addition, to think critically and deconstruct the
images and messages presented to us, speci®cally those glorifying thin-
ness and dieting.

Gender

Concern about physical appearance has been found to be twice as common

in women than in men (Harris and Carr 2001). Female self-esteem is often
6 Overcoming body image disturbance

conditional on perceived attractiveness (Guiney and Furlong 1999). Cul-

tural messages articulate standards of attractiveness and unattractiveness
and express gender-based expectations that tie femininity and masculinity
to certain physical attributes. When women de®ne their self-image too
tightly by body image, this is at the cost of developing an authentic sense
of self.
Body concerns are increasing among males, especially during adoles-
cence (Pingitore et al. 1997) and in gay men (Herzog et al. 1991; Williamson
and Hartley 1998). However, men's evaluation of their body is less likely to
affect their overall self-esteem in the way it does for women (Polce-Lynch et
al. 1998). For men, there is evidence that the cultural norm for the ideal
body has become increasingly muscular. Some idealised male images
exceed the upper limit of muscularity attainable without intense exercise
and/or anabolic steroids.

Age

Girls learn from a very young age to carefully self-monitor and improve
their appearance in order to seek social approval. Adolescents are parti-
cularly vulnerable because they are seeking external information to help
form their self-identity. Young adult women with a low level of self-
con®dence often believe that their looks are responsible for any failures
they have experienced (Probst et al. 1997). Body dissatisfaction or its
salience tends to decrease with age, but middle-aged and older women
also experience body dissatisfaction and diet in an attempt to lose weight
(Lewis and Cachelin 2001; Whitbourne and Skultety 2002).
 Body image and body image disturbance 7

Family attitudes and social learning

Expectations, opinions, verbal and non-verbal communications are also

conveyed in interactions with family members, friends, peers and even
strangers. Parental role-modelling, comments and criticism express the
degree to which physical appearance is valued within the family,
potentially establishing a standard against which a child makes a self-
comparison. Studies have shown correlations between parents' concerns
about their own and/or their children's weight, and body dissatisfaction
in their daughters (Slade 1994). Siblings can also provide a standard for
the comparison and appraisal of one's looks. Siblings, especially brothers,
are frequent perpetrators of appearance-related teasing or criticism. Peer
teasing regarding physical appearance is common in childhood and
adolescence and predisposes individuals to body dissatisfaction. There can
also be modelling of negative body image and pressure to diet from peers,
particularly in schools or colleges.

Body image and obesity

It is widely assumed that people who are obese must feel bad about their
bodies. This assumption re¯ects the powerful social stigma against
obesity. Research, however, shows that while obesity is linked to poor
body image (actual body weight is one of the strongest predictors of body
dissatisfaction), the severity of this varies considerably. Further, variability
in body image among people who are overweight is not related to their
degree of overweight.
In overweight people, negative body image is higher among

females;
those who were obese as children;
those with a history of stigmatisation (Myers and Rosen 1999);
those with binge eating disorder (Eldredge and Agras 1996).

Other risk factors

A positive self-concept may facilitate development of a positive evaluation

of one's body and serve as a buffer against events that threaten one's body
image. Conversely, poor self-esteem may heighten one's vulnerability
towards body image.