‘Body image’ refers to the mental picture that a person has of her own body. It is therefore based on how she feels about her body, and not on its actual physical appearance. People with AN tend to have a very negative body image. Look at Figure S6.1. Do you recognize any of the statements in the diagram as comments you have made about how you feel about your own body?
Figure S6.1 Body image distortion in AN
It is not unusual to mistake strong feelings for facts (e.g. ‘I feel lumpy all over, therefore I must be lumpy all over’). This is, however, a thinking error (emotional reasoning; see Table S4.1 on p. 157). These feelings can become so strong that the person becomes convinced that her body actually looks as bad as it feels. The result is body image distortion, one of the most distressing features of AN.
Julie, a 25-year-old student, had suffered from AN for two years. When she initially came for help with her eating disorder she had a very distorted body image. Despite being within the normal weight range for someone of her age and height, she was convinced that she looked ‘pudgy’ all over and that her thighs and buttocks were out of proportion to the rest of her body. As she described herself, ‘I just wobble like a jelly.’ She could not try on clothes in shops because she felt so ashamed about how she looked and hated places that had numerous mirrors. Whenever she felt down, she dwelt on how fat she was, and whenever she was anxious, e.g. before a job interview, she would get very unhappy and all she could focus on was how awful she looked.
Like Julie, many people with AN tend to feel worse about their bodies when they are feeling low and hopeless in general. It appears that any negative feelings about themselves can be very readily displaced into feelings of fatness. These negative feelings can be the result of all sorts of things. This is especially clear for Julie before her job interviews. She looks in the mirror prior to going into the interview and sees herself as fat and ugly. In this instance she may well be displacing other negative thoughts, such as anxiety about the interview going badly, on to her body.
Misplacing feelings about yourself on to your body sets up a potential problem: losing weight and trying to change your body shape does not really solve anything as the underlying issues remain unchanged.
As can be seen from Figure S6.2, body image dissatisfaction can begin when someone focuses solely on the negative aspects of their body and disregards any positive features. It can arise from dissatisfaction with the whole body or with part of the body; in the latter case that dissatisfaction is then generalized over time. The way someone feels about their body is often reflected in how they view themselves as a person. The last stage of Figure S6.2 shows that having a negative or distorted body image may seriously undermine an individual’s self-confidence.
Figure S6.2 Interaction of thinking error and body image distortion
Perfectionism can result in a negative body image. The media provide us with an image of the female, in particular, that is portrayed as the ‘ideal body’. This image itself is often a distortion: photographs of models are frequently elongated to make the model look taller and thinner than she really is. Therefore very few people can even approach this ideal body shape. Indeed, some ideas of beauty stress the rarity value of ‘beauty’, and what is considered beautiful or ideal in any particular culture is nearly always unachievable by the generality of the population, e.g. small feet in China, plumpness in some Third World countries, thinness in Western society. However, people who feel that they have to achieve perfection in all aspects of their life can quickly become obsessed with the fact that their body is not how they want it to be, and this leads to distortion of their own image and further distress as they strive to reach an unattainable goal.
If you avoid looking at and touching your body, and recognizing it as it is, this can perpetuate negative feelings about it, possibly to the extent that you become phobic about your body, or parts of it. As with all phobias, the best way of overcoming this is to reduce avoidance behavior and confront the fear. The more you avoid the subject of the phobia, the stronger the phobia becomes. Therefore, the rest of this Step sets out some suggestions for ways you can come to accept and appreciate your body more. Like all the other stages in this program, they will take perseverance and practice.
While you are carrying out these activities, use the cognitive techniques you have learnt to challenge thoughts about your body.
Understanding where your negative body image or even body hatred comes from may help you gradually change it. One way of doing this is to write a history of your body and the way you view this.
Learning to accept or even like your body again is not going to be easy. It is going to take a lot of time and a lot of repetition of small simple tasks. Here are some things that may help.
Re-writing the story. Re-write your story as though you hadn’t developed a negative body image. What would have been different? Would you have been more effective at changing things within the family? Would relationships have worked out differently? This may be hard to do and it may feel unbelievable, but try and persevere. Anything which puts different ideas, alternatives, in your mind may help.
Create an alternative body image (schema). Make this a kind, warm, benevolent compassionate ‘you’. One that is not critical of you, not judgmental, less perfectionistic. Take this other ‘you’ around with you. Imagine it sitting on your shoulder or standing behind you. When you have negative body experiences, listen to what it has to say about you and the way you are.
Try to disregard the media. Not all women with AN develop their problem because of media images or media pressure, but some do. Remember that we live in a very distorted world. Images that you see in magazines and on TV are frequently unreal. They are photographed in certain ways with particular lighting, they are often air brushed and sometimes vertically distorted. You may have had the experience of seeing someone famous and being surprised at how much shorter and dumpier they actually looked in real life compared with on the screen. Repeatedly say to yourself when you see these images: this is not reality this is a distortion.
Keep a positive diary. Your body image has been maintained by thousands of occasions when you have said to yourself something critical about your body or negatively compared yourself with others. Anorexia nervosa causes you to focus on these negative aspects and miss out the positive ones. Try and experiement for a week, only noting down positive or pleasurable experiences you have in relation to your body and ignoring the negative ones. This will help you correct the bias that is built into your thinking.
The following suggested activities may help you to think more about your body image distortion and focus on why this may have come about. For each exercise, set aside some time when you know that you will not be required to do anything else and will have peace and quiet. You may find it helps to work through each one on paper. It is a good idea to use a notebook – it could be the same one in which you keep your food diaries, or a different one – to record your thoughts and feelings as you work through these exercises; you will then have the notes readily to hand and can refer back to them when you want to in the future.
1 Try to imagine yourself in 10 or 20 years’ time. Where are you and what are you doing? What are your aims and ambitions? Ask yourself if you are on track for achieving these goals, or if you need to make changes. Write your goals down, and look at them when you are low and in need of a focus.
2 Look at who you are now. Ask yourself how you see yourself, and write this down. Then ask yourself how you think you are seen by others, and write this down. Compare the two. What are the differences and what are the similarities? Turn over on to a new page. Consider how you would like to see yourself, and how you would like to be seen by others. Write both down. What would need to be changed in order for you to be seen as you would like, both by yourself and by others? How would you go about making such change or changes?
3 Think of some woman who impresses you yet is not excessively thin. It may be a relative, a friend, an actress, a sportswoman, a businesswoman . . . What is it that impresses you – that makes you notice and respect her? It could, for example, be style, posture, confidence, energy, vivaciousness, intelligence, sense of control and purpose, or any one or more of a number of things. Ask yourself if you have any of these qualities; if not, think what you could do to cultivate them. Do you think weight and shape are of such importance to the person you respect? If not, what do you think is likely to be important to her?
4 Stand in front of a mirror and look at your body. For each negative statement you come up with about your reflection, make yourself say something positive – even if you do not believe it yet. Write these positive affirmations down and practise repeating them when you find yourself criticizing your body. Though this will feel quite forced to start with, try to persevere.
5 Does your body image restrict you in any way? Are there some things you avoid doing? Examples may be looking in a full-length mirror, wearing a bikini on holiday, trying on clothes in a communal changing room, using communal showers, etc. Write a list of these and make a resolution to try to confront rather than avoid these uncomfortable situations. Try to do these things and see if you can think differently. For example, when changing in a communal changing room, or sunbathing on holiday, look at other women’s bodies. Are they perfect? Would you swap? Usually the answer will be no. Be critical: think of a reason why you prefer your body to theirs; remember this, and record it in your notebook.
6 Pamper yourself physically. Though you may be in a pattern of being critical about yourself, take time to look after what you do have. Treat yourself to a long, luxurious, hot bath and afterwards spend time massaging aromatic oils into your skin from head to toe. Take time to linger on each part of your anatomy and try to counterbalance each negative thought with a positive one. If you think ‘My thighs are so fat and flabby’, set against this ‘My skin feels so soft and smooth’. Put on some nail polish, have a make-over, try a new hair style or shade. Make the effort to be kind to yourself, and try hard to stop being habitually self-critical.
7 Let’s talk exercise. Do you do exercise for pleasure – or out of guilt and anxiety? What is exercise for? For your pleasure, enjoyment and fulfilment? Or to burn calories and fat and make you thinner? I suggest it may be the latter. If so, try to think of something you would actively enjoy doing: if you really do want to be physically active, perhaps a dance class, or aqua-aerobics; or it could be something less strenuous, such as seeing films, visiting art galleries, reading novels. The important thing is to allocate time for activities you genuinely enjoy. If it helps, write down a selection of possibilities and score them on a scale of 1–10 for enjoyment. Make the effort to give highest priority to the ones you think will give you most enjoyment.
As you try to break the cycle of body image distortion and renewed urges to eat less and get thinner, ask yourself the following questions. They may help you to be more aware of the patterns of thought that have become habitual to you, and of why you think the way you do, and so help you to begin to break the automatic connection between perceived/distorted body image and self-esteem that re-inforces the symptoms of AN.
The key point is to try to break the connection between how you view yourself as a person and how you visualize your body.