Cognitive Behavior Therapy as a Treatment for Body Image Dissatisfaction

Catherine Faucher

Cognitive Behavior Therapy for body image has been proven an effective way to improve body dissatisfaction. It has been applied to persons with eating disorders, obesity, body dysmorphic disorder, and normal weight, all of whom harbor negative feelings toward their bodies. It is critically important to target body image for specific treatment, as negative feelings about one's body are often a major precipitous to eating disorders.

What is body image?

Body image can be defined as the picture one has in his mind about the appearance (i.e. size and shape) of his body, and the attitude that he forms toward these characteristics of his body. Thus there are two components of body image: the perceptual part, or how one sees his own body, and the attitudinal part, or how one feels about his perceived bodily appearance (Gardner, 1996). A negative body image can be in the form of mild feelings of unattractiveness to extreme obsession with physical appearance that impairs normal functioning (Rosen, 1995).

How do Americans feel about their bodies?

The 1997 Psychology Today Body Image Survey revealed that Americans have more discontentment with their bodies than ever before. Fifty-six percent of women surveyed said they are dissatisfied with their appearance in general. The main problem areas about which women complained were their abdomens (71 percent), body weight (66 percent), hips (60 percent) and muscle tone (58 percent). Many men were also dissatisfied with their overall appearance, almost 43 percent. However body dissatisfaction for men and women usually means two different things. More men as opposed to women wanted to gain weight in order to feel satisfied with their bodies (Garner, 1997).

Body image and eating disorders

Dissatisfaction with one's body can be used as a diagnostic criteria for eating disorders. A negative body image is associated with both anorexia and bulimia nervosa. Patients with binge-eating disorder also report significant amounts of distress over body image (Rosen, 1995).

Recovery from anorexia or bulimia in terms of eating habits or weight restoration does not indicate that the patient is satisfied with her physical appearance. In fact, about two-thirds of these "recovered" patients still worry excessively about their physical appearance. For many women, getting over the desire to be thin is the most difficult part of recovery. Body image must be targeted for treatment in eating disordered patients (Rosen, 1995).

Body image in non-eating disordered subjects

Body image is also a significant concern for those suffering from body dysmorphic disorder (BDD). BDD is a disturbance of body image in which the patient has a preoccupation with an imagined defect. These patients are not necessarily concerned about overall body shape, their problem area may be much more specific. Nevertheless, BDD patients can also benefit from treatment for their negative body image (Veal et al., 1996).

Finally, many weight-preoccupied and obese women harbor negative body images about themselves. They do not suffer from any disorder listed in the Diagnostic and Statistical Manual, but they are extremely body-dissatisfied. It is also appropriate for these women to receive treatment for the negative attitudes they hold toward their bodies.

Treatment for negative body image: What is Cognitive Behavior Therapy?

Cognitive Behavior Therapy (CBT) is a psychotherapeutic approach that can be used to treat body image disturbances. It is administered in a group setting with a therapist, or the program can be more self maintained by the patient through modest contact with the therapist. CBT is often modified into different formats in order to target the specific population in therapy, such as bulimics or weight-preoccupied women. Some studies reviewed in this article based some portion of their cognitive behavior therapy on Cash's (1991) program, which consists of eight 30 minute cassettes and a patient workbook to supplement therapy sessions. A pattern of treatment sessions for all studies can be similar to the following example, used in Grant and Cash's 1995 study. First, the patient creates a self-assessment of how their negative body image developed; second, the patient learns to keep a diary about events that surround poignant moments of extreme body dissatisfaction; third, there is relaxation training; fourth, is desensitization to body exposure through imagination; fifth, sixth and seventh, is when the patient realizes and adjusts errors in body image judgement; eighth, is identifying "self-defeating avoidant and compulsive body image behaviors;" ninth, is using different strategies to reduce these negative behaviors; tenth, the review of new cognitive and behavior skills and learning how to implement them in difficult interpersonal events that provoke negative body image; and eleventh, to practice relapse-prevention strategies (Grant & Cash, 1995).

Although all programs are not identical to this one, Grant and Cash's (1995) model provides a good example of the types of activities found in cognitive behavior therapy for body image dissatisfaction.

Normal weight women with negative body image

A. Group therapy and modest contact

Grant and Cash (1995) looked at body dissatisfaction among non-eating disordered normal weight woman. They studied 23 extremely body dissatisfied woman who followed Cash's (1991) body image cognitive behavioral therapy under one of two conditions: either in a group therapy situation or in a self-directed program with only modest contact with a therapist. Treatment was provided in 11 therapy sessions over the period of four months. In their current study, Grant and Cash found that patients can achieve comparable success to group therapy when following a self-directed format with modest therapist contact. After cognitive behavior therapy, patients in both subgroups became less appearance-schematic and less invested in their physical appearance, reported fewer negative thoughts about their body image, fewer cognitive errors in evaluating their appearance, and worried less about becoming fat. This body image therapy also enhanced self-esteem, decreased social anxiety, and alleviated some depressive symptoms (Grant & Cash, 1995).

One limitation of this study was that it did not involve a no treatment, or "waiting list" condition. However, previous studies have revealed that body image CBT is superior to minimal or no treatment. In addition, these findings do not suggest that a purely self-help model of treatment is as effective as group therapy. The results merely show that the two programs produce the same types of results in relation to negative body image (Grant & Cash, 1995).

A. Group therapy and minimal treatment

Rosen, Saltzberg, and Srebnik (1989) studied the effects of CBT for body image versus minimal treatment (control condition). Subjects were 23 normal weight, body image disturbed women, with no history of eating disorders. Treatment was provided for six weeks in a group therapy format. Patients in the minimal treatment condition followed a pattern of treatment similar to the experimental condition. The difference between the two formats was the absence of structured exercises to specifically deal with altering the pattern of negative cognitive and behavioral strategies. Essentially, minimal treatment was missing the key ingredients that accounts for the efficacy of CBT (Rosen, Saltzberg & Srebnik, 1989).

Rosen, Saltzberg, and Srebnik found that the full treatment of cognitive behavior therapy is "effective in improving body image disturbance in college aged, non-eating disordered women." Patients improved on all three dimensions (perception, cognition, behavior) of body image marked for treatment. Furthermore, patients showed clinically significant improvement in body image satisfaction both at the post treatment and follow-up evaluations. Patients in the minimal treatment demonstrated modest improvements, but the results were not clinically significant (Rosen, Saltzberg & Srebnik, 1989).

This study is limited in its generalizability because its sample consisted of all college-aged women, and the results may not apply to other populations. If the sample size was increased and the duration of treatment extended, then it is possible that these results might be applicable to other groups. Finally, it is uncertain if the disturbance of body image experienced by these women was of clinical significance, and a more comprehensive assessment of subjects is necessary to make the findings more clear (Rosen, Saltzberg & Srebnik, 1989).

Obese patients with negative body image

Rosen and al. (1995) produced one of the first studies that examined CBT for negative body image among obese women. Negative body image is a major concern for many overweight women because obese persons have real, not imagined, weight problems and they often face negative stereotypes. Subjects in this study were 51 obese women randomly assigned to CBT or no treatment. Treatment consisted of eight small group therapy sessions targeting negative behaviors such as overvaluing of physical appearance, continuous body checking, avoidance of situations that induce negative body images, and challenged negative stereotypes of obesity (Rosen et al., 1995).

Rosen and al. found that cognitive behavior body image therapy is an effective treatment for body image disturbance in obese women. In spite of the fact that CBT did not completely eliminate body image dissatisfaction, obese patients improved in body image. In addition, global self esteem improved in all non-clinical subjects. Furthermore, it was shown that improvements in body image were independent of changes in weight, which was the opposite of what many patients expected (they felt if they were more accepting of their obese bodies, they were more likely to gain weight) (Rosen et al., 1995).

This study failed to do a follow-up evaluation longer than four months, so it is not known if the effects of treatment versus no treatment are long-lasting. Rosen et al. might consider attempting to do a longitudinal study, and then they could also evaluate what factors in the environment facilitate or inhibit the success of CBT on obese patients. It would also be helpful if CBT for body image in obese persons was integrated into a weight-loss program (Rosen et al., 1995).

Body dysmorphic disordered patients and negative body image

Rosen, Reiter, and Orosan (1995) focused their research of CBT and body image on subjects with body dysmorphic disorder (BDD). BDD is a "distressing body image disorder that involves excessive preoccupation with physical appearance in a normal appearing person." These researchers provide the first controlled evaluation of cognitive behavior therapy for persons with BDD. Fifty-four subjects with BDD participated in the study, and they were randomly assigned to a treatment or no treatment condition. Patients were divided into small groups for eight therapy sessions, of which the context was similar to other therapies previously described (Rosen, Reiter & Orosan, 1995).

Rosen, Reiter, and Orosan found that cognitive behavior therapy for persons with body dysmorphic disorder proved to be an effective treatment. The majority of patients no longer met the DSM-IV criteria for BDD after completing the therapy. Moreover, global self-esteem improved, and preoccupation with appearance and body dissatisfaction decreased (Rosen, Reiter & Orosan, 1995).

Although the overall results show success for CBT, there were still some patients who had BDD at the follow-up assessment. Rosen, Reiter, and Orosan felt that these patients may have benefited from treatment longer in duration and more individual attention during the therapy sessions. In addition, it is nearly impossible to control what happens outside the clinic and how events may adversely effect treatment (Rosen, Reiter & Orosan, 1995).

Concluding analysis

Cognitive behavior therapy has been proven more effective for groups like weight-preoccupied women, obese women and those with body dysmorphic disorder than for subjects with eating disorders. This is quite possibly the case because body image therapy is only a portion of the psychotherapy for eating-disordered patients, whereas for other groups therapy focuses exclusively on improving body image. Assuming this is true, it is necessary to strengthen body image therapy programs for those with eating disorders so that they are more effective in alleviating body image disturbance. Furthermore, psychotherapists might do more thorough evaluations of body image by pursuing ideas beyond simple weight and shape (Rosen, 1995). Finally, negative body image assessment and treatment could be a key factor to the treatment of eating disorders. Researchers must continue to use results and practices to these studies and apply them to patients with severe eating disorders. By grabbing the root of the problem, a negative body image, it might be easier to succeed in successfully and permanently rehabilitating these patients.

References

Garner, D.M., (1997). The 1997 body image survey results. Psychology Today, 30, 30- 41.

Grant, J.R., & Cash, T.F., (1995). Cognitive-Behavioral Body Image Therapy: Comparative Efficacy of Group and Modest-Contact Treatments. Behavior Therapy, 26, 69-84.

Rosen, J.C., (1995). Body Image Assessment and Treatment in Controlled Studies of Eating Disorders. International Journal of Eating Disorders, 20, 331-343.

Rosen, J.C., Orosan, P., & Reiter, J., (1995). Cognitive Behavior Therapy for Negative Body Image in Obese Women. Behavior Therapy, 26, 25-42.

Rosen, J.C., Reiter, J., & Orosan, P., (1995). Cognitive-Behavioral Body Image Therapy for Body Dysmorphic Disorder. Journal of Consulting and Clinical Psychology, 63, 263-269.

Rosen, J.C., Saltzberg, E., & Srebnik, D., (1989). Cognitive Behavior Therapy for Negative Body Image. Behavior Therapy, 20, 393-404.

Veale, D., Gournay, K., Dryden, W., Boocock, A., Shah, F., Willson, R., & Walburn, J., (1996). Body Dysmorphic Disorder: A Cognitive Behavioural Model and Pilot Randomized Controlled Trial. Behaviour Research and Therapy, 34, 717-729.