After Weight Restoration: CBT for Body Image

As noted in my previous blog post and the comments that follow, full nutrition and weight restoration will often reduce or eliminate the body image disturbance that plagues so many people with Anorexia Nervosa (AN). This is one of the many reasons why it is essential for AN treatment to require full nutrition and prompt weight restoration.

On the other hand, some people with AN continue to experience intense body dissatisfaction after weight restoration. In these cases, Cognitive-Behavioral Therapy (CBT) can help improve body image and reduce suffering.

In order for CBT to be effective, the patient has to have some motivation to engage in the treatment and some desire to improve her body image. The patient also needs to have the insight to understand that her body itself is not the problem, so changing her body weight or shape is not the solution. Rather, the problem is that she has some negative thoughts, feelings, and behaviors related to her body that cause her to suffer. It is those negative thoughts, feelings, and behaviors that will be the targets for intervention. The insight, motivation, and judgment required for effective body image treatment is yet another reason why this intervention is most effective after full weight restoration.

Many of the CBT-informed interventions for body image are similar to those that are effective in treating anxiety and depression. Consider the following:

Cognitive Restructuring
This involves identifying and challenging distorted automatic thoughts related to one’s body image. Examples of distorted automatic thoughts include: “My thighs are enormous,” “I’m the fattest person in this room,” or “Everyone is staring at me because I’m huge.”

The patient may need some help identifying distorted thoughts because they may seem normal or accurate to her. Once she is able to identify a distorted thought as such, the patient is asked to keep a log of the thoughts as they occur. With the help of the therapist, the patient then learns to identify patterns of distorted thoughts, challenge her own thinking, and generate more rational thoughts to replace the distorted ones.

For example, “Everyone is staring at me because I’m huge” contains distortions of over-generalization and mind-reading. Is EVERYONE really staring at you? No. In a room of 30 people, maybe 2 are looking at you. That isn’t everyone. Do you know for sure that they think you are huge? No, because they didn’t say anything of the sort. Why else might they be looking at you? Maybe they like your shirt.

Exposure and Response Prevention
This involves systematically desensitizing the patient, little by little, to her body image fears for the purpose of improving her quality of life. For example, if the patient loves the beach but can’t bring herself to go because she is ashamed of her body in a bathing suit (this is a frequent scenario in my South Florida-based practice!), the therapist may begin by helping her create a hierarchy or “ladder” of challenges increasing in difficulty. The patient would need to “master” each task before moving on to the next one.

For example:
1.) Go to the beach with your best friend at a time when very few people are there, wearing a shirt and shorts over your swimsuit.
2.) Go to the beach with your best friend at a time when very few people are there, wearing just shorts over your swimsuit.
3.) Go to the beach with your best friend at a time when very few people are there, wearing just a shirt over your swimsuit.
4.) Go to the beach with your best friend at a time when very few people are there, and spend 2 minutes wearing just your swimsuit.
5.) Go to the beach with your best friend at a time when very few people are there, and spend 10 minutes wearing just your swimsuit.
6.) Go to the beach with your best friend at a time when very few people are there, and spend an hour wearing just your swimsuit.
7.) Go to the beach with your best friend when many other people are there, and wear a cover-up.
8.) Go to the beach with your best friend and spend 2 minutes wearing just your swimsuit.
9.) Go to the beach with your best friend when many other people are there, and spend 10 minutes wearing just your swimsuit.
10.) Go to the beach with your best friend when many other people are there, and spend an hour wearing just your swimsuit.
11.) Go to the beach without your best friend and wear a swimsuit the whole time.

Environmental Alterations
Once a patient is able to recognize patterns in her negative body image thoughts, she can choose to focus her attention on people, places, and activities that promote positive thoughts and feelings, while reducing or eliminating the negative influences. For example, if a patient has a friend who engages in a lot of “fat talk,” the patient may be assertive with this friend and ask her to stop talking this way around her, or she may decide to stop spending time with this particular friend and hang out with more supportive friends instead. Likewise, if following fitness Instagram accounts makes the patient feel badly about her body, she may decide to stop following these accounts.

Along these lines, many patients find it helpful to donate their outgrown, tight-fitting, or unflattering clothes to charity. The feeling of tight clothes on the body, or the sight of too-small clothes hanging in the closet, can be very triggering. Most people feel much more confident wearing comfortable, flattering clothes.

Eliminating Body Image Rituals
Some people engage in “body checking” rituals, which may be anything from measuring their wrist circumference with their fingers, grabbing the flesh of their belly, spending excessive time in front of the mirror, or trying on 10 different outfits before finding one that looks “just right.” These types of rituals may reduce anxiety in the short term, but they end up becoming self-perpetuating and increasing body dissatisfaction in the long-term.

CBT for body image can be done with a CBT-oriented therapist who has experience working with eating disorders and body image concerns. In my practice, I sometimes use CBT for body image in weight-restored patients with AN after their family has completed a course of FBT (only if it is needed and requested, of course!). I also use it in patients with Bulimia Nervosa (BN) or Binge Eating Disorder (BED) after eating patterns have been normalized, and with non-eating disordered patients who suffer from anxiety or depression and also happen to have struggles with body image.

However, improving body image does not necessarily require a therapist’s help. A motivated patient may be able to utilize these interventions on her own, or with the help of a parent, using internet resources or a guided self-help workbook. I often recommend Thomas Cash’s The Body Image Workbook, 2nd Edition.

There are other interventions for body image derived from 3rd wave behavioral therapies such as Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT). These will be the topic of my next post.

21 Replies to “After Weight Restoration: CBT for Body Image”

  1. Dear Dr. Ravin,
    I have just discovered your blog and have read it quite attentively. I am living far away in Europe and hence must use your online resources without a possibility of a consultation. I have a 19 yr old daughter who has been sick since 5 years. She is weight restored but never accepted treatments. She was hospitalized against her will. Now she is away at university, has a boyfriend and still struggles with eating and many compulsive behaviors. She always rejects speaking about AN or about her situation. Would you advise sending her a link to your blog? I fear she will reject me and punish me with the usual few months without contact, but some rational thoughts like yours could encourage her to accept and seek treatment.
    Thanks very much,

    1. Jose,

      I am sorry to hear that your daughter is struggling with symptoms but resists treatment. I don’t think it would hurt to send her a link to my blog. She may reject the information, but if you believe there is a possibility that it could help her, then I think it is worth a try.

  2. Sarah,
    My observation is that there is a group of people who suffer from anorexia nervosa who don’t fit into one of the three categories you described in your previous post, and probably should be identified with a fourth. These are athletes in endurance sports such as long-distance running, or weight-classification events including, for example, lightweight division rowing or wrestling. These individuals in many instances don’t dislike their bodies. In fact, often they love their bodies. The problem is that their bodies are at a weight that is too low for medical and psychological health. Their concern, however, is that if they gain significant weight, it will hurt their athletic performance or even disqualify them from their weight classification. In other words, these people don’t “hate their bodies,” have BDD, or “bad body image.” They just don’t want to gain weight for reasons that seem logical to them, given their dedication to their athletics.
    As these people begin to gain weight (often as a result of parents’ intervention to reefed them) they initially experience anxiety because they are often being required to give up their passion — their sport. At the same time, they are experiencing physical discomfort that accompanies re-feeding (see Minnesota Starvation Experiment). Furthermore, they don’t know when the process of weight gain will end and therefore often experience the anxiety of the unknown. Eventually, once these people are restored to a healthy weight, however, they are typically surprised how much better they feel: more energy, more enthusiasm for life, less anxiety. The role of parents is to help these people through this difficult process.
    Once these people have gained weight and are feeling better, the negative body image they expected to experience often does not materialize.

    1. Chris,

      I have worked with a number of patients with AN who fit this description: those who love and take pride in their bodies, in part because they have experienced some sort of social reinforcement (such as enhanced athletic performance) for their low weight or body shape. I think these folks are a subset of category #3 that I mentioned in my previous post – those who present for treatment without body image concerns but who develop increasing distress and anxiety as they gain weight. Their fears about weight gain are quite logical given the context in which they are operating (such as athletics, dance, acting, modeling, or other appearance-driven pursuits). For those who are professional [athletes, dancers, models, etc], their entire livelihood and self-concept revolves around weight, appearance, and physical performance.

      Fortunately, as you describe, these individuals often feel much better after weight-restoration as their physical and mental health improves dramatically. For these individuals, it is especially helpful to develop other interests outside of the activity that initially triggered the unhealthy weight loss.

      You also refer to another important point – the fact that anxiety and discomfort during re-feeding is often largely a function of the re-feeding process itself, and not necessarily indicative of AN symptoms or other underlying pathology. The end result, therefore, is that many people who experience re-feeding anxiety and distress, and the associated body image concerns, will move through these issues naturally as their bodies and brains reach homeostasis.

      1. These athletes don’t benefit by being given a psychiatric label. In fact, they are harmed.
        When given a diagnosis of mental illness, they and their families tend to get funneled into dysfunctional and inappropriate treatments that only make things worse.

        The athletes that I know have done really well when their parents, not therapists, are in charge of helping them gain weight and resume normal patterns of eating behavior. The best-available scientific evidence supports this conclusion. I realize that saying this is taboo in some quarters. (Such as, for example, to the leaders of F.E.A.S.T. Families Empowered and Supporting Treatment of Eating Disorders) Fortunately, however, things are starting to change. Parents are now empowering themselves. They are realizing that is is a serious mistake to rely on the shrinks because their methods have been proven to be relatively ineffective in helping people gain weight, compared to the common sense of parents.

        1. Chris,

          The problem is not the diagnosis of AN per se. Rather, the problem is ineffective treatment for AN that 1.) excludes or marginalizes parents and 2.) minimizes the importance of full nutrition and weight restoration. Sadly, much of the AN treatment available makes one or both of these mistakes.

          Evidence-based approaches such as Family-Based Treatment (FBT) which 1.) empower parents to take charge of their child’s recovery with the support and guidance of a trained clinician and 2.) Prioritize full nutrition and weight restoration have the highest rates of success.

          Contrary to the message of most professional ED organizations, then, the ideal solution is not to tell parents that they must seek professional treatment when their child has AN. Nor is the solution to advise parents to steer clear of professional treatment. Rather, the ideal solution is to provide parents with information to empower them to make their own choices.

          For example, parents [and adult patients] should be informed of the necessity of full nutrition and prompt weight restoration. Parents [and adult patients] should also be informed of the various treatment options available for AN, as well as the empirical data (or lack thereof) to support these approaches.

          Most parents that I know, when provided with this information, will feel empowered to seek out evidence-based treatments such as FBT and will have very positive outcomes.

          When families do not have access to effective treatment, due to geographic location, cost, or other constraints, then a common-sense based approach, such as the one you describe, in which parents re-feed their child and help him or her re-establish normal eating patterns may be the best available option. I am frequently contacted by parents in this situation – those who have educated themselves about AN and want to pursue FBT, but cannot access it due to cost or location. In many of these cases, I have advised parents to take charge of their child’s recovery by re-feeding and re-establishing normal eating patterns. Parents can access books and articles through my website and through the FEAST website, as well as parent-to-parent support through FEAST, to help guide them through this process.

          In sum, I think it is doing parents and patients a disservice to advise them to pursue one of two extremes – either always seek professional treatment or steer clear of professional treatment. I believe that we serve families best when we advise them to seek effective treatment or, when effective treatment is inaccessible, to educate themselves to support their child’s recovery without professional treatment.

          1. If your child is 18 years, or younger, the option with the strongest evidence-base is Family Based Treatment, if you want to involve a professional. However, it’s not clear from the research that any input from the professional therapist makes much of a difference to the outcome. Many parents are capable of using the principles of FBT and succeeding on their own without the involvement of a professional therapist. Furthermore, very few professionals are trained in FBT. The majority use treatment methods that are inconsistent with FBT and often undermine its effectiveness. Even those trained in it have a strong tendency not to adhere to it, but instead engage in “therapist drift” as shown by research studies.

            If your child is 19 years old, or older, you will have a very difficult time finding a professional therapist willing to use FBT. For that age group, there is no proven treatment for anorexia nervosa. Professionals have tried a variety of approaches, with low rates of success. For example, Janet Treasure, an advisor to the group you mentioned, F.E.A.S.T., participated in the development of
            a method known as the Maudsley Model of Anorexia Treatment for Adults. In a study published earlier this year, only 11.11% were recovered at 6 months and only 22.41% at 12 months. Schmidt, The Maudsley Outpatient Study of Treatment for Anorexia Nervosa and Related Conditions (MOSAIC): Comparison of the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) with Specialist Supportive Clinical Management (SSCM) in Outpatients with Broadly Defined Anorexia Nervosa: A Randomized Controlled Trial, J Consul Clin Psychology 2015, Vol 83, No. 4, 796-807.
            Many parents don’t like these odds — 11% and 22% are not acceptable. Many of these parents are convinced the principles of FBT are better, especially the emphasis on weight restoration and normalization of eating behaviors, rather than on emotional issues. Since these parents can’t find a professional who will help them use FBT with adult daughters and sons, they go it alone. My observation is that they are experience success at rates far higher than 11%-22%.
            This post began with a discussion of CBT for body image dissatisfaction. As discussed in the Nature article, above, there are no proven professional treatments for this condition. CBT is merely experimental at this point. So it’s hard to say that professional treatment is necessary or that parents are irresponsible if they opt to address the problem without professional input.

          2. Chris,

            I have never said that professional treatment is necessary for body dissatisfaction, nor have I said that “parents are irresponsible if they opt to address the problem without professional input.” Quite the contrary. At the end of this blog post, in fact, I specifically state that body dissatisfaction can be treated effectively without professional support.
            I believe that patients and their families can utilize interventions derived from CBT to achieve good outcomes without professional support. This is analogous to your observation that that families can utilize FBT principles to achieve good outcomes. Incidentally, I do agree with you that many families can utilize FBT principles to achieve good outcomes without professional support. As I mentioned in a previous comment on this thread, I advise parents to utilize principles of FBT on their own when they do not have access to effective professional treatment.

            With regards to CBT for body image, the research support at this point is more than just experimental. Clearly, more research is needed, but I would say that the results of studies conducted thus far are encouraging. The Nature article that you reference cites a 2014 study published in Behavior Therapy describing a clinical trial in which people who received CBT experienced a 50% success rate after 12 sessions, compared with just 12% of people who did not undergo treatment.
            The Nature article also mentions an iCBT intervention in which participants go through an internet-based CBT protocol with minimal professional involvement. Research on this intervention, though preliminary, supports my belief that many people can overcome body dissatisfaction with minimal, if any, professional involvement.

          3. Sarah,
            I agree with you that it does a disservice to parents to tell them to always seek professional help. An example is the Parent Toolkit published online by the National Eating Disorders Association. On page 17, it states that “Recovery from an eating disorder requires professional help.” This statement is false. There have been many instances in which parents have successfully treated a son or daughter’s anorexia nervosa without professional help. There have also been many instances in which professional help has not only failed but made things worse by, for example, disempowering and undermining parents. The idea that professional help is required tends to be promoted by organization such as the National Eating Disorders Association that rely upon funding from professionals for their existence. In other words, these organizations are mouthpieces for special interests. They aren’t interested in science or logic, just promoting an agenda.

          4. Let’s look at the question of professional treatment of eating disorders from one financial perspective. Assume that everyone who is diagnosed with an eating disorder should receive professional treatment for it. The Eating Disorders Coalition, the lobby group in Washington, DC, says on its website that 30 million Americans have an eating disorder. Many professionals contend that about 75% of those who suffer from an eating disorder should be treated as outpatients, and about 25% with 24-hour-a-day care. An example is Dr. Ken Weiner of the Eating Recovery Center in Denver, who made this statement in an interview broadcast by TV station WIAT in Alabama not long ago. (The video of the interview is online.) What would it cost, therefore, if we assume that 25% of 30 million people — 7.5 million — should be treated in an inpatient hospital or residential center? According to the Frisch article in the International Journal of Eating Disorders the average cost of residential treatment (in 2007) was $1,000 per day and the average length of stay 60 days, resulting in total average cost of $60,000. If 7.5 million people are given this residential treatment, therefore, we will, as a country, spend 60 billion dollars on residential treatment of eating disorders (7.5 million x 60 thousand dollars) This would result in a 20% increase in the total amount spent on health care in the United States. Each American would be paying about $2,000 extra in insurance premiums –$8,000 for each family of four — so that 7.5 million people can be treated for eating disorders in a residential treatment center. I doubt the public will support this idea. As a practical matter, therefore, unless a high percentage of families resolve the eating disorder on their own, without significant professional involvement, the cost of providing this treatment would likely bankrupt the health care system in the United States.
            The Eating Disorders Coalition is currently lobbying Congress to pass the Anna Westin Act which, among other things, would require insurance companies to pay for residential treatment of eating disorders. Mr. Weiner’s clinic, the Eating Recovery Center, is a financial contributor to the EDC lobby group. Obviously, the Eating Recovery Center, as a residential treatment facility, stands to gain financially if the bill is enacted into law, regardless of whether it is good public policy or not.

          5. Sarah,
            You write (above) that “the problem is not the diagnosis of AN per se.” However, in many respects it is. A person who has received a formal diagnosis of anorexia nervosa will have many opportunities closed to her for the rest of her life. For example, the United States Army considers both “current and history” of anorexia nervosa to be a Disqualifying Medical Condition. In order to be licensed as a doctor, lawyer, or other professional in some states, the applicant must reveal any history of psychiatric diagnoses, and a diagnosis can be a basis for exclusion. I’m convinced that parents, therefore, should think long and hard about whether they want to burden their child by allowing a shrink to slap a psychiatric label on her, particularly since the formal definition of AN is now so vague under the DSM-5. If your kid is underweight and has restrictive eating habits, why not simply feed her more food and help her re-establish normalized patterns of eating behavior, on your own, rather than getting a shrink involved?

  3. Dear Dr. Ravin,

    Thank you for a fabulous blog.
    I understand intrinsic motivation is a key factor here.
    Is there something that can be done to pave the way for motivation to flourish ?
    Thank you for your enlightening articles!

    1. Neomi,

      Are you asking specifically about motivation to improve body image, or about motivation to recover from AN in general? If it is the latter, I would refer you to my previous blog post on this topic. The last section of this post describes ways to help motivation flourish:

      If you are referring specifically to motivation to improve body image, then I would wonder why the person does not feel motivated to improve her body image, if negative body image is causing her to suffer. Some people mistakenly believe that they must dislike their bodies in order to stay motivated to “fix” them, which leads to a state of being constantly at war with one’s own body. In other words, some people believe that if they accept themselves as they are, then they will be “letting themselves go” and will just get fatter and uglier. This is faulty logic, and research actually shows the opposite: people who feel ashamed of their bodies are less likely to take good care of themselves, whereas people who love and accept their bodies are more likely to make health-promoting choices.

  4. I need to re-read this post because there is a lot that I need to absorb, and reading it right now, when I feel like complete crap in my body, might be a good thing. I will definitely come back to this post and read it again when my head is not filled with all of these negative thoughts.

  5. Hi! My name is Bettina Hinder and I live in Chelsea,MA. I have read your blog post about After Weight Restoration: CBT for Body Image « Dr. Sarah Ravin | Eating Disorders, Depression, Anxiety, Psychotherapy and I want to say that I am quite impressed with your professionalism on the subject!

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