Do Individuals with Eating Disorders See Their Own External and/or Internal Beauty?

Abstract

It has been well documented that individuals struggling with eating disorders don’t have clear perceptions of their own bodies. Yet they overly rely on their body image as their sense of self. Even the criteria of certain eating disorders recognize that individuals are strongly affected by their body weight and shape, which is often seen through a distorted lens. Individuals with eating disorders, particularly anorexia nervosa, struggle not only with recognizing their external beauty but also their internal positive qualities. Their perfectionism and critical sense of self leads them to have negative views of their beauty and self-worth. This chapter will look at some of the reasons individuals with eating disorders struggle to appreciate their own beauty, internally as well as externally, and will offer some tools to help with these struggles. Many individuals, even those without disordered eating, struggle with critical self-perception. Perhaps this chapter can help us all become more compassionate to ourselves as we consider our external and internal aspects of beauty.

1. Introduction

Individuals with eating disorders often don’t recognize their beauty. Those suffering from anorexia nervosa and bulimia nervosa struggle with accurate perceptions of their body weight and shape and unduly rely on body weight to define self-worth. [1] It is important to recognize that these individuals value themselves based on their weight and shape and yet often cannot accurately assess themselves in the physical dimension. I have worked with individuals in our eating disorders clinic who were emaciated but yet feared coming into a medical appointment because they would be weighed. The fear was not only about the number, which causes anxiety for many individuals with eating disorders, but a fear that they were so heavy that they would break the scale and/or exam table. One patient described that when he walked, he felt like he was breaking tiles because he was so heavy. He was actually severely underweight. Individuals with eating disorders struggle both in recognizing how they actually look and appreciating the beauty of their healthy bodies. They rely on their body weight to help define their self-worth and when they feel so negatively about how they look, they also struggle with seeing positives in themselves even their internal qualities.

When I have asked individuals in groups to share something that they like about themselves, they often describe that they like how they care about other people. They do not hold this same level of care or compassion for themselves. Individuals, particularly those with anorexia nervosa, can struggle with “repressed narcissism” such that they put other peoples’ needs before their own. This can lead them to completely disregard their own needs, wants and desires. They see themselves as not worthy of being taken into consideration. These negative views can become intertwined. They see their body in a negative light and yet rely on their weight and body shape to define their self-worth. This can make them feel worthless and that negative feeling can contribute to them being even more self-critical about their worth and their body.

Additional challenging traits, such as perfectionism, are often associated with eating disorders and can further undermine a person’s acceptance of his/her uniqueness and value. Perfectionistic tendencies makes it difficult for many individuals with eating disorders to complete certain tasks (such as sending emails) but also makes it hard for them to acknowledge their positive traits. They are often are so self-critical that they can never match their internal expectations. When asked in groups how they would define another person’s success, the answer would often be, that the person would be successful if she tried her best. So if in school she got a “B” or a “C” but had tried her hardest, that person should still be seen as a success. However if they themselves didn’t achieve a 100 percent on an assignment, then they saw themselves as worthless. Often there was a vast difference between their expectations of others and their expectations of themselves. Studies have linked disordered eating with body dissatisfaction, low self-esteem and perfectionism, especially in girls. [2] They struggle not only with dissatisfaction of their external beauty but struggle with their internal acceptance of self. The do not see their external or internal beauty.

Another chapter in this text, Blossoming for Whom? Social Approval and Body Image, looks at the role of social acceptance and body image disturbances in individuals struggling with eating disorders. [3] When individuals are faced with images and expectations that are not achievable, their own sense of beauty can be affected. Models are not only much thinner than the average woman but hours of styling and then subsequent photo-shopping make media images unattainable. If one bases her sense of value on external beauty standards, then it is understandable why she struggles with her sense of self when measured against these unrealistic expectations. If individuals struggling with eating disorders, do not see themselves in a realistic way, measure themselves against unreachable goals and link their self-value to these external perceptions, then it is understandable why they underestimate both their external and internal beauty. In addition, when individuals struggle with self-criticism and perfectionistic expectations, they often do not recognize their internal positives and by extension the beauty of their soul.

Are there ways to help individuals who struggle with eating disorders challenge these negative views? Can any of these tools help others who might not struggle with an eating disorder but who also struggle with low self-esteem and a negative view of self? My clinical roles include not only work within an eating disorders clinic but also providing therapy to students at Penn State College of Medicine. It is clear from my work with these individuals that although many do not struggle with eating disorders, they often struggle with a negative sense of self. Many describe elements of “the imposter syndrome”, which affects many individuals even those functioning at a very successful level. They worry that they will be found out—that even though they have been successful and have received praise, it is only because they are fooling other people. When others discover who they really are—they will be seen as an imposter. How can any of us accept ourselves and discover our external and internal beauty? It seems like an impossible task considering all of the expectations that are placed on us. For individuals who struggle with eating disorders this journey can be even more difficult. Yet part of recovery will be working to discover and accept their own unique beauty.

While eating disorders and negative body image can affect all individuals, including men, my examples will be mostly from women that I work with in my clinic. They make up much of my treatment group. Some studies have suggested that body image disturbances and subsequent eating disorders occur at higher rates in groups of individuals who are trying to develop relationships with men because these women or gay men are often judged by their physical attractiveness. [4] In many societies, especially Westernized society, women are often evaluated and judged by their physical appearance. They are often exposed to comments or actions that focus only on their external appearance and objectify them as sexual possessions. Exposure to sexually objectifying comments can have a significant negative influence on women, not only when those comments are made directly but even when they are experienced secondhand. [5] It is for these reasons that this chapter will mainly focus on the experience of women, as they battle their illnesses, their negative self-perceptions and negative self-evaluations. They often don’t see their external or internal beauty. Perhaps, there are ways to help them discover and accept their positive traits.

2. Body image

Body image is “a person’s mental picture of how good or bad their physical appearance is, especially when compared with how they think they should look”. [6] Within this simple definition, one can already see part of the difficulty because it focuses on how we think we should look. A comparison is introduced even in the definition. Comparisons can exacerbate negative perceptions, especially when comparing oneself to unobtainable images and struggling to accurately perceive oneself. “Your body image is what you think and how you feel when you look in the mirror or when you picture yourself in your mind. This includes how you feel about your appearance; what you think about your body itself, such as your height and weight; and how you feel within your own skin.” [7] Body image encompasses many elements. Individuals who struggle with eating disorders, particularly anorexia nervosa, can have challenges with the perception of their bodies when they look in the mirror or see pictures of their own images. They not only feel negatively about themselves but can also struggle to perceive their bodies accurately.

When women struggling with an eating disorder were presented with an image of themselves and asked to photo-shop the image to what they believed they looked like, they routinely distorted portions of their body making themselves appear much heavier. This was opposed to a control group who made minimal adjustments to the images and accepted the photograph as an actual representation of how they looked. [8] Other studies indicate that individuals with anorexia nervosa might not overestimate their body size but that the disturbance comes because of their distorted view of a desired body. [9] This was further substantiated by [8]. When individuals with eating disorders photo-shopped their bodies to a desired state, these images were often extremely distorted and demonstrated unrealistic body goals. One study [10] suggests that individuals without an eating disorder often rate themselves as more attractive than others rate them. Whether this is true for the majority of individuals is not clear. It does seem, though, that individuals who do not struggle with an eating disorder often have a more compassionate relationship with their bodies. They recognize what their bodies do for them rather than being disconnected from their bodies. An individual with anorexia nervosa has disturbances that affect the person’s functioning such that it is difficult to experience his/her body as an integrated aspect of self or develop a coherent narrative over time. [11] Clinically, individuals with anorexia nervosa often seem at war with their bodies, often seeing them as something that can be manipulated and brought under control even as these actions are taking them further and further away from being able to function in life. For women with bulimia, when they were asked to focus on their bodily sensations and estimate the width of their body, they overestimated their size by 13%, while the controls’ estimates of how wide their bodies “felt” corresponded to actual sizes. [12] A positive body image is associated with psychological well-being. [13] It is clear that we need to consider how individuals can come to love their bodies and their selves.

3. Body dysmorphic disorder and obsessive compulsive disorder

Anorexia Nervosa and Body Dysmorphic Disorder (BDD) appear to share certain characteristics, such as a distorted and dissatisfied perception of one’s body. The similarities and differences, i.e. how they are classified can be important to consider. As [14] notes, although they are classified differently—under feeding/eating disorders for anorexia nervosa and obsessive compulsive disorders for body dysmorphic disorder—their similarities may warrant classification as “body image disorders” and benefit from therapies that target body image disturbances. This overlap is important to consider as is the role that obsessive compulsive symptoms may play within eating disorders, specifically anorexia nervosa. Clinically, a number of patients whom I have worked with who struggle with anorexia nervosa often demonstrated obsessive compulsive tendencies. Typically their obsessive–compulsive behaviors revolved around food—not wanting to mix foods, needing to eat foods in a certain order, requiring a certain number of chews per bite, calculating and recalculating calories for the day to ensure that the total is correct. The intertwining of obsessive–compulsive behaviors and anorexia nervosa is interesting when considering a study that looked at emotional intuitiveness for individuals struggling with OCD (obsessive compulsive disorder). The authors [15] found that people with high obsessive–compulsive tendencies had more difficulty accessing internal states because of their continual doubting. Constant monitoring of thoughts can use up cognitive resources that can then make it difficult for individuals with OCD to have the resources available for actually experiencing the emotional states. [15] As individuals get more distant from their internal states, they start to doubt their own experiences or feelings and this can develop into a negative cycle. This is important to consider because individuals with anorexia nervosa often seem disconnected from their emotions. Often they use the illness as a mode of control and as a way to numb away feelings of discomfort. In [15] they suggest that many emotions do not stand up to constant monitoring but anxiety can “survive” this constant assessment and may even increase. These connections underscore some of the challenges for individuals with eating disorders as they try to recognize both their external and internal beauty. Individuals with anorexia nervosa share characteristics with BDD and as such cannot accurately assess their body and their external beauty. They often see it in a distorted perspective. The significant OCD tendencies that we see in individuals struggling with AN can affect their assessment of self. The disconnection with their emotions and the constant swirl of anxiety can make them doubt much of their inner life and challenge their recognition of their own emotional states and inner beauty.

4. Genetics

There are many ways that genetics can play a role in the perception of external and internal beauty in individuals with eating disorders, especially anorexia nervosa. One aspect relates to the genes that determine body shape and size. I have worked with young adolescent girls who were caught up in very negative dieting and other weight control behaviors as they struggled against the set-point of their bodies. Looking at their parents, it was clear that they had genes that kept them shorter and heavier than they desired. While they would acknowledge that they couldn’t control or affect their height, they believed that their weight could be manipulated and controlled. This is a belief that most people seem to share. There is truth in this up to a point. If we eat more calories than we burn, we will gain weight. However, we each have certain physical characteristics that are determined by our genes. Some individuals will be taller or shorter, thinner or heavier, large bosomed or have a smaller chest size. One challenge is that much of Western society is weight-biased and so the messages that are given to individuals affects their ability to see their larger body as beautiful. When weight bias is internalized, it can lead to a lower quality of life, such as lower self-esteem. [16] This then affects individuals’ “inner beauty” as they feel less positive about themselves.

Genetics also affects temperament and can influence how individuals feel about themselves. Individuals with restrictive eating patterns and a low body mass index demonstrated a repressed form of narcissism, such that they put others’ needs before their own. [17] This is important to consider. How can one recognize her own value, self-worth and thereby inner beauty, if she is always sacrificing her needs to the needs of others? This brings us back to the earlier observation about the groups that I ran when I asked individuals what they liked about themselves. They often have a hard time identifying anything positive.

5. Influence of family

Family interactions can perpetuate eating disorder behaviors and negative attitudes towards oneself, especially related to negative comments offered by other family members. Family has the most powerful influence on values and norms related to appearance. [18] Clinically, I have seen many times how a mother’s focus on her body dissatisfaction influences a daughter’s body image dissatisfaction. One young woman was struggling to recover from severe anorexia nervosa and had to deal with her mother constantly asking if certain clothes made her (the mother) look fat or the mother would quiz the daughter about the number of calories in a certain food because she knew her daughter had all of that information present in her mind. It was hard for my patient to disengage from her eating disorder or not worry about her body image when she was constantly fielding these questions from her mother.

While modelling behavior can influence individuals’ body image and body dissatisfaction, evidence suggests that parental comments and active encouragement to diet can have an even greater influence on their child’s body concerns and eating behaviors. [19] Types of comments can vary with mothers focusing on health but dads and siblings making more negative comments and participating in teasing. [20] Positive feedback can improve self-esteem of individuals with eating disorders. [21] This is important for providers to remember because often our patients are attuned to negative feedback. We need to ensure that we approach them with an encouraging attitude. Too many times, clinicians do not consider the impact that their words will have on their patients. I have worked with clients who started down the road of an eating disorder because they were pushed to diet by a physician. We need to remember to focus on health and recognize that health can come at different sizes. Often physicians parrot the weight bias that is present in Westernized society. We need to work with families where individuals have been on the receiving end of negative comments and teasing and encourage the families to make a shift to neutral or positive comments. This can be hard but needs to be practiced. The family—especially parents—need to understand the negative effect that their comments can have on their child’s self-esteem. [22]

6. Influence of peers

Many clients that I see in the eating disorders clinic describe weight-related teasing prior to the development of their eating disorder. The literature does support the fact that weight-related comments lead to body dissatisfaction and negative weight control behaviors. One study looked at the long-term effect of weight related bullying and examined whether there was a difference if the bullying occurred in the family or from peers. The authors followed a group of adolescents for 15 years and found that weight-based teasing in adolescence was associated with negative weight control actions even as adults. This included eating as a coping strategy, more body dissatisfaction, higher BMI and obesity risk. [23] Within this study, the authors found that the source of teasing (whether family or peers) had the same negative effect on girls but peer teasing had an increased effect on boys. [23] They were not certain whether girls were subject to more weight-related teasing than boys within their families or whether sensitivity to societal expectations related to weight and body image made girls more susceptible to the effects of teasing. Within their study, teasing also occurred irrespective of whether the individuals were overweight, obese or even underweight. In [24], the authors found that overweight or obese children who experienced teasing by their peers struggled with more depressive symptoms and also participated in more unhealthy weight control behaviors as a result of this teasing. It is clear that weight-related teasing by peers can have significant and long-lasting effects on individuals.

Another factor related to peers is that individuals with eating disorders often interpret ambiguous social interactions negatively. For example, when girls were asked to interpret social vignettes, those in the eating disorder group tended to attribute more hostile intent. For example, when given the situation that your best friend didn’t invite you to their birthday party, the control group made the assumption that the friend, of course, expected her to come and advocated for checking out the issue by talking with the friend. Individuals with eating disorders, on the other hand, rarely picked the option of talking to the friend and made negative assumptions of the situation—that the friend had only been pretending to like her. [25] These social situations would often propel the patient group to consider using eating disorder behaviors rather than trying active ways to evaluate their negative assumptions. These concerns led to more anxiety in social situations and potentially more isolation from peers. To deal with these feelings of rejection, individuals often turn to eating disorder behaviors. This influences their sense of self and their self-esteem. Often they feel that the only thing that they have in their life that can consistently make them feel better is their eating disorder.

When considering self-esteem, we need to consider how it develops. Contingent self-esteem describes the relationship between receiving social approval and positive perception of oneself. Essentially one’s self-esteem and positive feeling about oneself is dependent upon other’s positive views of him/her and their approval. This can lead to great concerns about one’s weight, which can then influence body surveillance, body dissatisfaction, lower self-esteem and eating disorder behaviors. [26, 27] We need to consider how we help individuals develop their own positive self-assessment rather than always looking for social approval. That does not mean that we want people to not care at all or to try and alienate others. It does mean, though, that we have to help them recognize that we can’t please everyone and that we need to feel okay about ourselves even if we meet with rejection in some social settings. In a recent session, a young woman, who suffers from an eating disorder, was struggling with how to handle her thoughts that others were always criticizing her or noticing if she gained a few pounds. She describes that she tried to handle her self-criticism by thinking why wouldn’t everyone want to date her. This is a fallacy as well. We need to recognize black and white thinking and the potential sticky beliefs we can get trapped in. Just as not everyone is rejecting her because of her “perceived” flaws; she shouldn’t expect everyone to overly accept her. The corollary from that would be that if someone rejects her then it is based on some aspect of her, rather than just the idea that we aren’t going to mesh with everyone. I asked her if she wanted to date everyone. She doesn’t. There are great people out there that for different reasons, we don’t want to develop relationships with them. That does not mean that there is anything wrong with them or with us.

7. Other influences

7.1 Teachers, coaches and school policies

Many others can influence how an individual perceives him/herself. In schools, more extensive weight-related teasing leads to lower self-esteem and greater body dissatisfaction in girls. [28] We need to establish safety for individuals in families and schools so that they aren’t continually subjected to negative comments. That means ensuring that teachers, nurses, administrators and coaches, for example, not only monitor their own comments and ensure that they are not making weight-based comments, but also ensure that weight-based bullying is squashed. Often weight-related teasing is not included in anti-bullying policy initiatives. [29] Yet it is an important challenge. There are ways that schools are possibly perpetuating weight focus and negative weight related behaviors. While one study suggested that weight-based teasing did not increase in schools even after introduction of obesity policies, such as measuring BMI and removing vending machines from schools, the teasing still stayed at 14% for overweight to obese children. [30] Since weight-based teasing can lead to negative health behaviors that can extend even into adulthood, it is clear that we need to continue to assess the effects of any interventions. Others studies have suggested that BMI measurements in schools can potentially lead to more eating disorder behaviors, especially if not handled correctly. [31] The authors point out that the CDC did not find enough evidence to recommend BMI report cards from schools. The challenge is that BMI is one number that if reported to parents can lead to a focus on weight and dieting. A higher BMI, though, could be related to a number of situations—an impending growth spurt or increased musculature from sporting activities. If families receive information about the BMI without guidance about what it means, more unhealthy weight control behaviors could occur, which can ultimately lead to more eating disorders or future obesity. [32] One thing to consider if we are working to try and improve overall health is whether eating disorder screening should occur in schools. In [33], we find that almost 15% of girls and 4% of boys score as having a possible eating disorder using the EAT-26. Since eating disorders have the highest mortality of any psychiatric disorders, strategies for early assessment and intervention would be useful. The SCOFF questionnaire has been suggested as a tool that could be used by school nurses to help identify children at risk for eating disorders. [34] As schools work to improve overall health and address concerns related to weight, this might be one assessment that should be implemented. With the current pandemic, the need for mental health assessment and interventions is being identified as being even more important. [35] It is incumbent on those in position of power/influence to consider the effect of their attitudes and words. Coaches can impact their athletes’ view of their bodies and either inadvertently or on purpose push athletes towards negative weight control behaviors. The authors in [36] describe not only comments made to them that indicated the views and assessments of their bodies by coaches and those in power but also the objectification by others. I have worked with many young women who were encouraged to lose weight so they could be more competitive, could run faster, would look better, etc. Mary Cain in a NYTimes editorial described how she was influenced by her coaches to get thinner and thinner until her body broke down. [37] One study found that while coaches did have an understanding of eating disorders, they, at times, didn’t understand the significance of some symptoms, such as amenorrhea. [38] The authors also found that coaches preferred to talk with teammates if they had a concern about an athlete rather than turning to specialists in the field of eating disorders. [38] It will be important to ensure that coaches are familiar with aspects of eating disorders and recognize the need to get athletes the care that they need.

7.2 Media

The effect of television and Westernization has been established through many studies. When television was introduced to Fiji, body image dissatisfaction and disordered eating behaviors increased. [39] This was replicated in Bhutan, which was the last country exposed to television. When this occurred, it led to a subsequent pressure to get thinner, look thinner and regulate one’s appearance based on media images rather than compared to one’s peer group. [40] Media has a strong influence, not only on distorted perceptions and expectations, but on how role models are perceived. Intense celebrity worship by young teens can have a negative influence on their body image. [18, 41] It isn’t clear which comes first—does obsession with a celebrity lead to poor body image or do individuals with poor body image gravitate towards celebrity fixation. Interestingly one study looked at body dissatisfaction, restrained eating and compared congenitally blind women, acquired blind women and sighted women. They found that these issues increased related to the extent of visual media exposure so that congenitally blind women had overall better body image because they had not been faced with the media’s distorted expectations. [42] In the tools, we will discuss the importance of media literacy which can help with body dissatisfaction. One program, ARMED, which offered a two session media literacy course demonstrated that 8 weeks after participating in the course, women who were at high risk for developing an eating disorder had less body dissatisfaction. A change was not noted for women at low risk for developing an eating disorder but they may be less influenced in their sense of self and their body image as compared to those at higher risk. [43]

7.3 Objectification

“Objectification theory posits that girls and women are typically acculturated to internalize an observer’s perspective as a primary view of their physical selves.” ([44], p.173) This can lead to habitual body monitoring, which increases shame and anxiety for many women. Seeing oneself as an external viewer of one’s body can also decrease awareness of internal body states. [44] We have seen that the connection with one’s body and reliable interpretation of internal body states can be affected for individuals who struggle with eating disorders. They often monitor their bodies and perform numerous body checking activities to evaluate how they should be feeling about their body. I worked with one young woman who agreed to not weigh herself but turned instead to measuring and recording the size of many of her body parts—circumference of thighs, etc. As with the objectification theory—she was seeing herself as just the sum of her parts, which is how the authors discuss their theory. “The common thread running through all forms of sexual objectification is the experience of being treated as a body (or collection of body parts) valued predominantly for its use to (or consumption by) others.” ([44], p. 174).

This objectification not only affects how they see and monitor their physical bodies but also how they function in their overall lives. “Again, though, the habitual self-conscious body monitoring that results from self-objectification might best be viewed as a strategy many women develop to help determine how other people will treat them, which has clear implications for their quality of life.” ([44], p. 180) Because they recognize that they are being objectified by others, they constantly need to scan themselves to assess how they will be perceived. Rather than being in the moment and living their lives, they are viewing and measuring themselves. It has also been demonstrated that women do not have to be personally targeted to experience the negative effects of objectification. [5] One mediating factor appeared to be that when individuals feel part of a group, they can experience less negative self-esteem stemming from sexism. [45] Feeling part of a group can be a larger challenge for individuals struggling with eating disorders. As we discussed earlier, they may have more negative evaluations of interpersonal interactions, which can leaving them feeling not a part of a group and turning more to their eating disorder. [25] This can affect this described mediating factor.

This objectification can be even more difficult for young girls as they progress through puberty. “Far beyond the idea that adolescent girls simply do not like the size and shape of their maturing body, girls learn that this new body belongs less to them and more to others.” ([44], p. 193) For many of my patients, going through puberty led to increased negative feelings about themselves. If they went through puberty earlier than others, they were often targeted for comments and felt self-conscious because their bodies looked different than others who were the same age. One patient described that when she went through puberty, her family made fun of her changing body—often it was her brothers but her parents did not intervene and on occasion, her father made comments. Now it is hard for her to gain weight; it is hard for her to develop curves or breasts. Others have commented about similar situations. After hearing her brother and father comment consistently on women’s breasts, a young woman feels very ambivalent and self-conscious about gaining weight and developing the same physical attributes that garnered so much attention from the men in her life.

7.4 Trauma

Trauma can affect an individual and her sense of beauty and herself. It can be associated with disordered eating; this is often because of negative emotions and thoughts. [46] I have certainly worked with individuals who blamed themselves for the attacks. This led to not only negative feelings but also the use of disordered eating to try and gain back a sense of control or to numb the negative feelings related to the trauma. The authors [46] also see these effects of trauma. Disordered eating can be a way to avoid unwanted attention and the individual may feel this is a way to keep them safe. [46] One woman whom I worked with had recovered from her eating disorder but was then a victim of a sexual assault. She began her pattern of restricting again. She described to me that if she was assaulted when she looked “healthy” and had curves, she needed to make sure she didn’t have that happen again. Others have described working to disappear. There is often an ambivalence—should I be thinner/smaller so that I am not noticed or since thinness is often associated with sexual objectification, will that draw more attention? It can put women in conflicted and negative associations with their bodies.

Emotional abuse contributes to negative self-perception, which then can contribute to disordered eating, including night eating syndrome and binge eating disorder. [47] One study found that adolescent girls who were exposed to traumatic life events or who had to navigate difficult family situations were at an elevated risk of becoming obese and in engaging in unhealthy weight control behaviors. [48] One study found that patients with bulimia were more likely to have a history of trauma as compared to other eating disorder diagnosis [49] What is even more significant from this study is that almost 35% of the adolescents being treated for eating disorders had a history of trauma. [49] A systematic review demonstrated an association between adverse life experiences and obesity and binge eating disorder. [50] Adults who have experienced one adverse childhood experience (ACE) were likely to have suffered multiple other adverse experiences during childhood. [51] This is important because ACES appear to have a cumulative effect such that as the number of events increases so does the effect on mental health. [52] It seems fairly obvious how abuse can undermine an individual’s perception of herself. This can lead to the use of food or disordered eating to try and control negative emotions. It can also influence acceptance of self and recognition of both external and internal positive qualities. I have worked with fabulous young women who do not seem to recognize any of their positive attributes because of being criticized and belittled by other’s in their lives—often family members. When working with clients with disordered eating, it is helpful to assess their perception of themselves and any history of emotional or other types of abuse.

8. Tools to help

1. In our eating disorder program, one therapist who runs a body image group presented at a conference with me [53] and outlined some exercises that she uses in groups to help individuals consider misconceptions or beliefs that they may harbor about their bodies. These tools also allow them to start to consider their body from the perspective of function—rather than objectification. As we have seen in this chapter, that can be a very important strategy. Some of the group ideas include:

   • Consider your body’s needs and rhythms. If someone was going to move into your body for the day, what important information would they need to know about it? What guidelines would you need to provide related to rest, feeding, watering, light/outdoors, physical activity, touching, soothing, healing--what keeps it functioning well?

   • A letter From Your Body to Yourself. Our bodies hear everything we think/say about ourselves…if it could write a letter to you, what would it say?

   • List three women/men you would like to be for a day and explain why it would be a great experience to be them. She finds that usually patients include individuals based on positives in their stories or their accomplishments and not often focused on appearance.

   • Letter to younger child/self. What would you tell a younger child or your younger self to avoid an eating disorder?

   • Body Checking reflection. What are you trying to find out and how does it help?

   • My Body Experience from then to now. A time-line for influential events and experiences that influence your body image. This can help individuals understand defining moments and beliefs that they developed about themselves.

2. We have discussed trauma as it relates to eating disorders. It is very important when working with individuals to have a compassionate strategy when eliciting a trauma history. It can often help when assessing trauma to start with opened ended questions. One that I like to use: “Has anything happened in your life that you are still struggling with? That has been hard for you to get past?” This will often lead to stories of losses in their lives, or previous bullying or heart breaking stories of violent death. A few things to keep in mind when asking these questions is that you will need to provide the space and support for the patient to share his/her story. When getting a trauma history, I don’t think that anything can be worse than being dismissive or uninterested. This will reinforce the sense that victims sometimes have that they are to blame for what happened. The other important thing is to be able to hold the difficult emotions that might come up in the session—both your reaction and that of your client. If someone shares a story of past trauma, they are demonstrating a belief that they can trust you. It is vital as a practitioner that you honor that trust. If the question that I shared above doesn’t elicit a story or depending on what they say, I do go through each type of potential past trauma. “Has anyone ever made you feel bad about yourself?” This can elicit emotional abuse, but if you don’t get an answer, you can ask about past bullying. As we discussed in this article, weight-related teasing/bullying can affect self-perception and lead to disordered eating. “Has anyone ever been physically harmful to you?” This is to obtain physical abuse. If in your history there has been any mention of substance abuse, you might want to add another question to ask that when so and so was drinking, did they become harmful to your or anyone else in your family? This will get their experience but also can elicit secondary trauma by witnessing abuse of someone else. “Are there any sexual situations that you have been put into that made you uncomfortable?” When getting this history, it is important to maintain eye contact so that the individual knows that you are interested. It is important to give them the space to answer. Do not group all types of abuse together and ask in such a way that it seems like it is just a box that needs to be checked off. I have seen individuals do that in evaluations—it doesn’t open up the necessary space. It doesn’t make them look interested. Also make sure that others, such as family members, aren’t in the room when you are taking this history. How can you ask about potential abuse and expect to get the truth if someone else is in the room, listening to the story.

3. When treating individuals with eating disorders, especially anorexia nervosa, there is a need for increasing the patient’s self-esteem and self-worth. [54] That does certainly seem to be a very important tool. It may be less clear how to accomplish this. One way would be to help patients recognize when they are having negative or critical thoughts about themselves. Sometimes this can occur so routinely that they don’t even stop to examine their thoughts or they believe that everyone harbors this internal self-criticism. It is important to clarify the patients’ thoughts and work to help them recognize them and challenge them. Is there another way to reframe the thought? For example, if someone is critical of themselves because of past abuse, can they instead view their resilience as a strength? Are there better ways to frame things—if they describe themselves as “stupid” because they didn’t do well on an exam, can you help them put this in a reasonable context? We all make mistakes or can fail at something but that does not make us total failures. Are they overgeneralizing? Are they turning one small setback into a catastrophe? One tool that I find helpful when faced with patients who harbor negative thoughts or self-criticism is to ask them if they would tell those same comments to a friend or family member. Typically they would not. The question then is why they feel that they should tell it to themselves. This can help them start to recognize when an interior monologue is helpful or when it is perpetuating a negative cycle.

4. Self-blame and self-distraction perpetuate an individual’s negative assessment. [55] Coping strategies can help with body comparisons and body dissatisfaction such that positive reframing can help individuals challenge negative views. What is positive reframing? Again, it is shifting from the negative point of view of not being good enough to highlighting positives. “I might not be as thin as her but I’m healthy.” “My body is strong and fit.” “I am more than just my body. I am a unique and talented individual.” Focusing on criticisms of ourselves can lead to more body dissatisfaction and overall self-despair. Studies have demonstrated that focusing more on body functionality can lead to more body positivity and self-acceptance. [56]

5. We can push our media to offer more realistic sized models. When individuals viewed images of full-figured women, they had improvement in their body appreciation. [57] Related to celebrities, especially those who offer thinspiration or appearance focused accounts, viewing these images can affect one’s body-image and body-acceptance. However, it has been found that exposure to parodies of these accounts can lead to improved body satisfaction and mood. [58] So go, have a laugh, feel better about yourself. One of my favorites is Celeste Barber’s recreation of other videos. [59]

6. Consider the impact of children’s toys as well. Girls exposed to Barbie dolls demonstrated lower body esteem and wanted a thinner body shape as compared with controls. While older girls didn’t demonstrate this same difference, there is a suggestion that exposure to dolls that foster an unrealistically thin body ideal may damage girls’ body image. [60] If you look at how many toys, especially super heroes, have changed over the years, one can understand that these subliminal expectations are not just being presented to young girls but also to young boys who are being pushed to desire increased muscularity. We need to push manufacturers to create more appropriate styled toys or consider the toys that we provide the children in our lives.

7. An impressive video, which was designed to address the unrealistic expectations that the media has been foisting on women, is the Dove Evolution video. [61] You can find it on YouTube. It shows a beautiful young woman being transformed into a model on a billboard—including make-up, hair and photo-shopping. It reminds us that the expectations that we are comparing ourselves to are not realistic. Can this have an impact? Yes, it can. When presented to a group of young women who watched music videos, it was demonstrated that this simulated commercial break had the potential to disrupt the detrimental effects of social comparisons with the idealized models. [62] All young women should understand that when they encounter the media, they are comparing themselves to manipulated and often unobtainable images.

8. Consider the impact of social network use. This can be a challenge, especially now in light of the pandemic, because so much of our social connections are occurring on-line. What can be helpful to realize is that not all social network use is equal in the potential negative impact on body image. It appears to be more appearance focused activities that can have a negative impact. Focusing on photographs on Facebook rather than amount of Facebook activity appears to influence thin-idealism. On Instagram, again spending time on appearance-focused accounts rather than appearance neutral had more of an impact on negative body-image and self-worth. [63] Body positive imagery, focusing on diverse beauty and functionality, can change the focus and improve body acceptance. [64] In addition, positive parental support and a strong school environment that teaches media literacy has helped mitigate the potential negative influence of social media. [65] This is important to consider. Research has demonstrated the negative and or positive effects that school environments can have on young adults. If schools don’t discourage weight-bullying, it has a negative impact. If, though, school officials recognize their role as positive influencers of our young adults and model positivity, media literacy, and appreciation of differences then they can have a constructive impact.

9. As per [18] parental spoken observations, both positive and negative, can have a significant impact on body-perception. Often observations and discussions of food and body can slip into conversations unnoticed—they have become so much a norm in many societies. Yet we all need to be aware of the potential our words can have on those around us, especially our children who are in the process of developing their sense of identity and self-worth. I wrote a previous chapter about communication challenges with suggestions of how to improve communication especially related to individuals struggling with eating disorders and low self-worth. [66] As discussed in family interactions, it is clear that different family members may interact differently—some in the guise of trying to help, some with critical comments or teasing. Different interventions may be needed depending on the ages or relationship of the individuals or the types of comments that are being made. [20]

10. Self-compassion can influence body-positivity, improve appearance self-esteem and buffer against risk factors. [67, 68] One must ask if there is any good argument against self-compassion. Many of our clients who struggle with eating disorders are very critical of themselves. If we can help them improve self-compassion, it may not only improve their positive feelings about themselves but could influence their willingness to care for their bodies.

11. There are programs that have been designed to help reduce drive for thinness and linking one’s self-worth to the approval of others. In Favor of Myself is one such program that helps adolescents cope with the challenges of their life stages. [69] This is important to consider. Different life stages lead to different challenges and potential coping strategies. I often work with adolescents who are struggling with trying to navigate middle school and high school. The desire for social approval in light of shifting alliances and bullying make it challenging for everyone but in particular those individuals who link their sense of self-worth to the approval of others. If we can provide tools to help our adolescents navigate these unsettling years, it can help improve self-confidence and positive coping strategies. Expand Your Horizon is a program than can help focus on body functionality, which we have discussed can improve body appreciation and decrease disordered eating. [70]

12. One area that needs more study is body image directed techniques, such as mirror exposure, video confrontation, and virtual reality body exposure. These techniques may be helpful in improving body image outcomes but evidence is still unclear. [71]

13. One study [54] suggested that patients with anorexia nervosa may have a left-hemispheric bias related to their body distortions. They suggest working to activate the patient’s right hemisphere by left-hand contractions or engaging the patient in EMDR (Eye Movement Desensitization and Reprocessing). This could be an interesting tool to include in future research.

14. Authors of [72] looked at movement from a negative body image to a positive sense of self during development from adolescence to young adulthood. Turning points included, finding a new and supportive social context, such as new friends or a romantic partner. This allowed individuals to have a feeling of belonging and acceptance. Another aspect was increased empowerment—excelling in certain sports or developing their unique style. Finally, they actively used strategies to practice body acceptance and valued themselves and their lives in larger contexts than just their body. From this study, we return to self-compassion again. It is important to help adolescents begin to consider how their body can help them lead a valued life rather than just focusing on its weight and shape.

9. Conclusion

It can be challenging for anyone to appreciate his/her external and internal beauty, but this is even more difficult for individuals who struggle with eating disorders. Photo-shopped media images bombard us and set up unobtainable expectations. Negative comments from others can affect body-image and self-esteem. Likewise attention that pushes individuals, especially women, to be seen as objects rather than whole vulnerable humans can affect sense of self and also perpetuate trauma. Healthcare practitioners and all humans need to consider how to encourage self-compassion and improve self-esteem. We need to help others see their own beauty and we need to recognize it in ourselves.

Conflict of interest

The author has no conflicts of interest.