Many eating disorder symptoms have to do with bodies: being preoccupied with your body, going to great lengths to change it, having a distorted sense of what it looks like. Given that, it would be reasonable to assume that eating disorder treatment would focus on body image issues right upfront—but this isn’t the case. In evidence-based eating disorder treatment, body image is actually one of the last areas to be addressed, if it’s addressed at all. This might seem counterintuitive, but there’s a reason behind it. Read on to learn more about why, how, and when body image should fit into treatment for the best shot at success.
What’s the relationship between body image and eating disorders?
Eating disorders and body image concerns often go hand in hand, but the Venn diagram isn’t a perfect circle.
Why is this? Research shows that body dissatisfaction is a risk factor for eating disorders, body image disturbance is one of the diagnostic criteria for anorexia and bulimia, and body image issues help maintain an eating disorder. Research also shows that those with binge eating disorder tend to have body image distress.
But it’s important to remember that not everyone with an eating disorder has body image issues; this is particularly true of ARFID, which manifests in significant food restriction but not out of a desire to lose weight or change one’s body. At the same time, not everyone with body image struggles has an eating disorder (and given how prevalent body image issues are today, the eating disorder rate would be extraordinarily high if this were the case.
Where body image fits into eating disorder treatment
No matter a person’s eating disorder diagnosis, the first focus in treatment is normalizing eating habits and gaining weight for those who need it. If a patient is actively engaging in eating disorder behaviors, their brain is likely malnourished—regardless of their weight—and a malnourished brain doesn’t think clearly or take in new information well. This means it’s tremendously difficult to make real progress in any other areas of treatment, including body image work, until patients have been able to reduce their eating disorder behaviors and achieve weight restoration.
“The main rationale for addressing body image in later stages of treatment is because starvation or undereating is known to impact a person's thought processes and may be directly contributing to body image-related concerns,” explains Shannon Patterson, PhD, therapist and clinical instructor at Equip. “Additionally, body image work can require a fair amount of cognitive skills that may be affected by disrupted nutrition.”
Those with lived experience have seen this play out in the real world. “I think addressing body image issues is important in recovery, but there’s a right time for it,” says Gabrielle Terzano, a peer mentor at Equip. “If I was forced to address body image issues in the beginning of recovery, I think I would have been more resistant to it. I think addressing the body image with a more nourished mind was important for me.”
Equip’s Director of Lived Experience, J.D. Ouellette, who helped her daughter through anorexia recovery, echoes this sentiment. “Our experience was that it wasn’t possible to address body image until my daughter had restored all the weight she lost and then some. During the time that she was undergoing nutritional rehabilitation and weight gain, body image issues were handled in the same way that eating and exercise interruption were handled: by validating the pain she was in, confirming confidence in the recovery plan, and offering distraction.”
The importance of body image work for long-term recovery
This is not at all to say that body image work has no place in eating disorder treatment. In later stages of treatment, addressing body image issues can be crucial for strengthening recovery and helping protect against relapse. “For many people with eating disorders, the ability to control one’s shape or weight is one of the hallmark features that keeps the eating disorder going,” says Patterson. “If we ignore the maintaining factor of someone’s eating disorder, it will be difficult to see lasting changes, and they may be at a higher risk of relapsing.
Indeed, unaddressed body image issues are associated with an increased risk of relapse after successful treatment. According to one study, patients who still overestimated their body size upon discharge were more likely to relapse, while another found that specifically targeting body image after initial eating disorder treatment can enhance treatment effects.
Patterson also sees body image work as an avenue for a deeper connection between the patient and healthcare provider. “Addressing body image in treatment allows the therapist to develop a greater understanding of the patient,” she says. “We’re able to see them not as a set of symptoms, but as a whole person. We learn more about a person's family, cultural heritage, and core beliefs about themselves and the world when we can address this important issue in therapy.”
However, for some, body image never becomes a focus of treatment. This is the case for patients without significant body image issues—like those with ARFID, for instance—but it can also be true for patients who do have body image distress. Patterson explains that this might happen due to a clinician’s lack of confidence in addressing body image concerns, or if a patient’s insurance coverage runs out before treatment providers have had a chance to shift the focus to body image. It also might just not be a part of a given treatment program. In an ideal world, all treatment programs would include a body image component to increase each patient’s chance of achieving lasting recovery.
At Equip, we take an individualized approach to addressing body image issues. For patients who struggle with body image, our providers use a variety of different evidence-based modalities to help them overcome their struggles and protect against relapse. We also have a targeted body image program that’s available to all patients, as well as the general public, and led by subject matter experts.
How is body image addressed in treatment?
There are a lot of different ways to tackle body image issues, but some are more research-backed than others. The primary evidence-based modalities include:
- Cognitive behavioral therapy (CBT). “Cognitive behavioral therapy approaches are often used to support people with body image changes, and this may include stopping body checking or avoidance behaviors,” Patterson says. “The therapist may work with someone on ‘body approaching,’ which is engaging in something that they may have previously avoided due to discomfort or fear about their body.” That might mean getting your photo taken by a friend or wearing a bathing suit at the pool, for instance.
- Dialectical behavioral therapy (DBT). DBT skills can be used to help people tolerate the distress or discomfort they may feel in their body and copy with body changes during treatment. For example, the DBT skill of radical acceptance can help a person move on when they don’t like what they see in the mirror, or the DBT skill of opposite action can push someone to go to a pool party when their instinct is to stay at home, showing them that their body doesn’t have to hold them back from enjoying life.
- Acceptance-based approaches. These approaches are used not to change a person’s thoughts about their body, but to help them change the relationship they have to those thoughts. For instance, rather than trying to change someone’s perception that their arms are too big, an acceptance-based approach would help that person challenge the idea that their arms being a certain size matters or means anything even if it is true.
Body image work might also include intuitive eating, media literacy strategies (i.e., learning to view media and its messages through a critical lens, rather than internalizing diet culture values), having gratitude for what the body can do rather than how it looks, and learning to engage in mindful, joyful movement. No matter the approach used, she says, the provider’s philosophy toward body and weight matters. “It’s crucial that providers incorporate a Health at Every Size approach to their treatment, which means that they are—at minimum—not pathologizing a person's weight, or perpetuating weight bias in their body image interventions,” she says.
Ouellette also points to the power of rejecting society’s thin ideal and weight bias. “Do the work of figuring out who benefits from you feeling terrible about yourself,” she says. “For my daughter, it was really helpful for her to become educated on the toxic forces at play designed to make people feel insecure about their bodies in order to control them and sell them things. Honestly, I highly recommend getting good and angry as the first step to shedding all the societal baloney around what constitutes a ‘good’ body and the idea it’s a mandate we strive for that and that if we can't achieve arbitrary, narrow, unattainable, standards, we are less than. Learn to value the true you; the you that is your heart and soul.”
Will body image be “solved” after eating disorder recovery?
Despite the many benefits of addressing body image distress, the truth is that it’s possible for people to complete treatment and find recovery without making peace with their body. “I think as a field we’re still trying to define ‘recovery,’” Patterson says. “Body image interventions can aid a person in coping with aspects of society that make recovery difficult—like weight bias, racism, accessing medical care, food insecurity—but it’s important to remember that recovery can’t exist in a vacuum. We have to acknowledge the impact that larger systemic issues have on our clients’ body image.” Indeed, these larger systemic issues can make it difficult for anyone, even those without an eating disorder, to feel fully comfortable and confident in their body all of the time.
Patterson also highlights the nuance and individuality of each person’s relationship with their body; because of how differently we all relate to our physical selves, each patient’s body image journey will look different. “It’s important to realize that everyone has the right to discuss their body image to the extent that feels comfortable to them,” she says. “It's also important to remember that many people lead a happy and fulfilled life without loving their bodies. I think that for many, healing doesn't necessarily mean that they no longer have body image issues, or that they love—or even like—their bodies. Instead, they’re able to build a full life and exist regardless of their body image.”
Terzano is living proof of this idea. “Something that really helped me is understanding that my perception of myself can change from day to day, even if my body hasn’t changed at all,” she says. “It was my attitude towards that perception that fueled my eating disorder behaviors. I started asking myself, ‘what do I really want to look like?’ Most of the time I didn’t have an answer. That’s when I knew that my body wasn’t the problem. It was my mindset.”
“Body image is one of the most challenging parts of eating disorder recovery, partially because body image doesn’t go away, even if you’re recovered,” Terzano continues. “You need to learn to remember that what you weigh isn’t more important than who you are. Focus on a lot of self-care: do a face mask, paint your nails, meditate, journal, wear comfortable clothes. This will pass. Keep going.”
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