Body image captures wide reach in eating disorders

Body image concerns among women are well-documented. Body image dissatisfaction has become somewhat of a normative experience for women. Can you remember the last time you heard a woman say, “I look good today”? More often you hear women tearing themselves apart and criticizing their every perceived flaw.

Yet now we also are seeing an increase in the prevalence of body image and eating disorder issues among men and sexual minorities. From my experience at The Menninger Clinic, a leading psychiatric hospital in Houston, I can attest that body image concerns are often heightened in those identifying as homosexual, and possibly even more pronounced in patients experiencing gender dysphoria who may identify as transgender.

With the growing number of male eating disorder patients, I have had the opportunity to work with several men identifying as gay who have communicated the intense pressures they experience to fit the ideal image of a muscular, tanned, fit, tall, well-groomed, sexy man. Some have said they feel this pressure may even be more pronounced than it is for women.

Now imagine desiring to be female but residing in a physically male body. Or imagine the dangerous strategies someone might employ to uphold the body ideal of their desired gender. A physically male adult desiring to be female may restrict food intake to avoid gaining weight or muscle. A physically female adult may over-exercise to attempt to develop a more muscular physique, but then restrict food intake to avoid developing curves.

These ideologies and behaviors produce a very different conversation about how one manages feelings about body image dissatisfaction. Body image dissatisfaction transcends the typical focus on weight and becomes all-encompassing. The conversation becomes one of how to help patients make peace with relatively unchangeable body parts that they do not feel are consistent with their sense of self. Assisting patients with body image struggles in these contexts proves especially difficult. While some opt for surgery and hormone therapy that can assist them in making peace with their bodies, others may not have the resources for those options, and in these cases body image work in therapy is essential to gaining peace of mind.

Body image therapy

I enforce with my patients the philosophy of radical acceptance and the idea of inherent self-worth; these are two evidence-based Dialectical Behavior Therapy (DBP) concepts that I have integrated into my work with eating disorder patients. In thinking through how we can help patients achieve body image satisfaction, I pose to clinicians that we must help patients identify how societal trends have caused us to forget that to be human is to be imperfect.

We know that patients often avoid mirrors because what they see is so distressing to them, especially when they see body parts with which they cannot identify. When we fear something or avoid it, it becomes bigger and more powerful in our minds. That’s why body image distortion represents another key factor of the work we must do with our patients. The parts of their appearance they struggle with the most become all they see, and often are incredibly pronounced in their mind.

I explain to patients that their image becomes somewhat like a phobia for which they use avoidance to cope, but that this ends up exacerbating the problem. This is a very challenging process, but when people can meet with their physical body without revulsion, and maybe even some compassion and acceptance, it becomes a powerful moment.

Our treatment for body image distortion includes helping patients reintegrate themselves with their body and end the avoidance. Our work helps patients connect with their body and foster a more positive relationship between their sense of self and their body. To do this, we have patients write letters to and from their body. This is typically a distressing but inspiring activity. Their body often provides too much distress to them to be allowed to come close to their consciousness, and this distance is often depicted in the letters they write. It often becomes an apology to the body for the way they have treated it, and a desire to treat it better. The letter also can serve as a plea for help or a reaching out from the body asking for integration and care. This is often patients’ first experience at connecting with their body.

Having patients create a timeline of their body image development helps them understand their feelings, emotions and overall experience. The acceptance happens over time, so giving them a way to track subtle changes, especially during treatment, allows them to focus on the positives of the experience. Further in the process, we engage patients in activities such as body tracings or mirror exposure, where we stand alongside them as they are confronted with their image. This assists them in eliminating avoidance and gaining a more accurate perception of their body.

Once patients garner more self-compassion and radical acceptance, and are able to look at themselves from a different perspective, we turn our attention to helping them respond to subtle interchanges with peers, family members, colleagues or even strangers who want to transpose their body image on the patient. This is where Menninger’s keen focus on mentalizing comes into play. Mentalizing shows the patient how to be curious about one’s own thoughts, behaviors, emotions and experiences, while being aware of the mental state of others and interpreting behavior accordingly.

Society’s impact on treatment

Research has demonstrated a genetic and biological component of eating disorders and body image distortion, but I think it is safe to say that our societal images of the “perfect” body type displayed on billboards, in magazines and everywhere we look online also play an integral role in our patients’ body image dissatisfaction. This becomes dangerous territory that can greatly affect depressive symptoms, anxiety and even suicidal thoughts, so we have to address all of these possibly co-occurring psychiatric disorders with our patients while in treatment, which generally occurs over four to six weeks here at Menninger.

As clinicians, our work changes as societal norms change. We’re seeing more openly gay and transgender patients because our society has become accepting of an individual’s sexual orientation, resulting in diminished stigma. According to Pew Research, 60% of Americans in 2013 believed that homosexuality should be accepted. That’s a significant increase from the 49% who believed the same in 2007.

This change in just six years shows us that we have to continue to work tirelessly to understand each patient’s individual expectations about body size and appearance so that they gain our trust over the course of treatment. Eating disorders are some of the most difficult mental illnesses to treat, and generate among the highest suicide rates. It's no secret that not all patients are ready to do the work it takes to confront body image issues and eating disorders. It is a scary process and may even be a patient’s worst fear. But if we are allowed to journey with a patient in this realm, we have to see our job as planting seeds and working through their ambivalence about change. It is a gift for the therapist, the client, and society as a whole.

Natalie P. Goodwin, PhD, is a second-year post-doctoral fellow in the clinical psychology training program at The Menninger Clinic in Houston. She serves as the clinician for eating disorders treatment, working with adult and adolescent patients who have a co-existing eating disorder that may or may not have been treated prior to admission.