The Body Image Problem

Weight- and body shape-related distress is typically a core feature of eating disorders.  In my experience, body image problems often predate the onset of eating disorder behaviors and linger after they are brought into remission.  Over the years, I have witnessed a variety of body image concern presentations.  Some patients experience a ‘fear of fatness.’  Others seem to derive a sense of control, self-esteem, or identity from their drive for thinness.  Some have a distorted perception of their body’s actual shape and size.   Others seem to have a realistic view of their bodies, but strive to meet unrelenting standards for thinness.  A minority of patients do not report body image struggles at all; they have related their eating disorder behaviors to themes of self-punishment, asceticism, or orthorexia.

To further develop McCallum Place’s body image-related services, I reviewed many of the leading psychotherapies for eating disorders to get their ‘take’ on the nature and treatment of body image disturbances.  To my surprise, only a minority directly address body image.

Interpersonal Therapy (IPT) assumes that binge eating and bulimic symptoms are related to interpersonal issues and that symptoms can improve if relational problems are addressed.  IPT targets one of four interpersonal themes:  unresolved grief, conflict in a specific relationship, a challenging role transition (e.g., going to college or getting promoted), and social skill deficits/an absence of relationships.  The theory acknowledges that cultural factors and weight/shape-based self-worth are relevant vulnerability factors.  However, my impression is that eating disorder symptoms are viewed as a way of coping with underlying relationship problems and therefore are not the focus of treatment.

Cognitive-Behavior Therapy (CBT), in contrast, directly addresses the over-evaluation of body weight, body shape, and their control.  Christopher Fairburn’s adaptation “Enhanced CBT” (CBT-E) assists patients in recognizing the harmful consequences of deriving such a high proportion of their self-concept from weight and shape and in developing other ways to value themselves.  The treatment also tackles avoidant and/or compulsive behaviors which are thought to maintain body image problems, i.e., body checking, obsessive weight checking, body avoidance, avoidance of knowing one’s weight, and comparing one’s body to others’.  The origins of the over-evaluation are explored.  The patient learns to cope with sudden experiences of “feeling fat” by identifying triggers and reframing the experiences.

Whereas CBT traditionally teaches patients to challenge unhelpful or distorted thoughts and beliefs, Acceptance and Commitment Therapy’s (ACT) focus is changing one’s relationship with such cognitions and other distressing physiological or emotional experiences.  Core treatment goals are decreasing avoidance, decreasing attachment to one’s thoughts, and increasing a present focus.  Patients commit to changing their behavior based on a clarified understanding of their goals and values.  I imagine these strategies can be applied to body image distress, as with other emotional difficulties.

Adolescent-Focused Therapy (AFT) for adolescent anorexia nervosa (AN) assumes that body image distress (and other AN obsessions and compulsions) ultimately serves as an avoidant coping strategy, rather than simply a problematic symptom.  Obsessions are thought to serve as a way of directing one’s attention onto the specific and controllable-feeling matter of weight, so as to distract from more complicated and uncertain developmental issues.  AFT posits that anorexic symptoms can improve once one of four underlying developmental problems is worked through:  the capacity to experience and assertively express anger and other strong emotions, self-esteem regulation, identity formation and integration, and separation-individuation.  I wrote a previous blog entry detailing AFT and its underlying theory.

Family-Based Therapy (FBT) for adolescent anorexia does not appear to directly treat body image issues, other than by reversing the dangerously low body weight which exacerbates obsessionality.  Additionally, the practice of weighing the patient in session and sharing the data likely serves as exposure therapy.

Dialectical Behavior Therapy (DBT) for binge eating and bulimia does not appear to directly address body image distress, either.  DBT instead focuses on increasing distress tolerance and emotion regulation skills to more effectively manage intense feeling states, so as to decrease reliance on binge eating and/or purging as a means of escape.  However, in practice, a DBT therapist may incorporate exposure strategies, acceptance, and the mindfulness concept of adopting a non-judgmental stance to assist with body image distress.

Radically-Open DBT (RO-DBT), an adaptation of DBT to address problems of emotional over-control, also does not appear to directly treat body image.  Instead, the primary target is over-control; themes of which include perfectionism, rigidity, self-criticism, and difficulty connecting with others.  The treatment assumes that eating disorder symptoms will abate as open emotional expression, flexibility, and social responsiveness replace over-control behaviors.

The Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) also appears to omit a focus on body image, instead targeting a constellation of factors related to the maintenance of AN:  increasing the motivation to recover, improving food intake and nutrition, addressing relationship problems, developing more flexible thinking styles, learning new ways to manage emotions, challenging pro-Anorexia beliefs, and developing a sense of identity outside of AN.  The module on flexible thinking is reminiscent of elements of RO-DBT.  FBT also originated at the Maudsley hospital in the United Kingdom.

While perhaps not an exhaustive list, what do these models imply for clinicians?  Are body image issues a sort of ‘primary problem’ which psychotherapy should attempt to directly tackle?  Or would such an approach be an uphill battle, at best, or a misguided effort, at worst?  Would it be better to conceptualize body image distress as a ‘secondary problem’ – a symptom of more directly treatable underlying issues – such as interpersonal problems, developmental conflicts, or inflexible thinking?  I also wonder about the implications for patients who may be wondering how they can relinquish eating disorder behaviors before their body image improves.  Should patients generally be encouraged to expect recovery to proceed in the reverse order?  A ‘chicken or the egg’ dilemma can emerge.  While the field continues to explore such questions, McCallum Place will continue to promote clinical programming which reflects a variety of reasonable theoretical perspectives in our group and individual psychotherapy efforts.

About John Rapp, LCSW, Therapist

John Rapp earned a bachelor of science degree in microbiology and immunology from the University of Wisconsin-Madison and an MSW from Washington University in St. Louis.  He is a licensed clinical social worker in the state of Missouri.  John started his career at McCallum Place and has returned as clinical director after four years as an outpatient therapist.   John is a psychodynamic therapist, aiming to help patients bring uncomfortable feelings and patterns into awareness, so they can better understand their own minds and more freely make desired changes.  He also has significant experience providing cognitive-behavior therapy, dialectical behavior therapy, and exposure therapy.  He specializes in helping patients become more emotionally and interpersonally regulated, so that they can relinquish the need for ineffective or self-destructive coping.

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