Intimate Partner Violence Among Women with Eating Disorders

Two conditions increased the risk in two studies.

Reprinted from Eating Disorders Review
January/February Volume 27, Number 1
©2016 IAEDP

The Centers for Disease Control and Prevention defines intimate partner violence, or IPV, as physical, sexual, or psychological harm by a current or former spouse or partner. IPV currently affects 44% of American women. By contrast, men are far more likely to experience violent acts from strangers or acquaintances than by an intimate partner (World Health Organization. 2002). 

Two recent studies have highlighted the increased risk among women with eating disorders during the perinatal period and among women with poor social support. 

Poor social support increased risk

Lack of social support increases the risk of IPV, according to results of a recent Penn State College of Medicine study (Int J Women’s Health. 2015. 7:919). Dana K. Schirk and colleagues examined the frequency of risk of eating disorders in adult women exposed to intimate partner violence and then assessed the effect of social support on the risk of disordered eating among these women. 

The HARK Questionnaire Have you been humiliated or emotionally abused in other ways by your partner or ex-partner? Have you ever been afraid of your partner or ex-partner? Have you ever been raped or forced to have any kind of sexual activity by your partner or ex-partner? Have you ever been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner?

The women, who were from 18 to 64 years of age, completed a screening survey examining health, demographics, and IPV exposure, as measured by the Humiliation-Afraid-Rape-Kick (HARK) screen. This 4-question survey (see table) accurately identifies women who are experiencing IPV. For this study the survey was modified to ask about both IPV exposure in the past 12 months and lifetime exposure. 

After the screening questions were completed, women were invited to leave their contact information if they wished to participate further. To protect the participants, safety and confidentiality steps were put in place, and the women were also given referral information for services for general health, domestic violence, mental health, substance abuse, and eating disorders. Individual social support was measured with the MOS Social Support Survey, which contains 19 questions about emotional informal support, tangible support, and social interactions. Risk of ED was assessed during the Eating Disorders Screen for Primary Care (ESP), a five-question screen.

When the researchers examined the risk of eating disorders among the 302 women with lifetime IPV, 14% were found to be at high risk, 42% at moderate risk, and 44% at low risk. Among women exposed to abuse, low social support was significantly associated with an increased risk of eating disorders, suggesting that social support may help protect women dealing with IPV against developing an eating disorder, if the women take advantage of the support. 

IPV during the perinatal period

Mothers with eating disorders and their children may be especially vulnerable to negative effects from IPV, according to Dr. Radha Kothari and a team in the UK (Int J Eat Disord. 2015. 48:727). In the team’s recent study of women participating in the Avon Longitudinal Study of Parents and Children, three groups were evaluated: women with lifetime histories of eating disorders (n=174), those without pregnancy shape and weight concerns and/or purging behaviors (n=189), and women with no history of eating disorders (n=8723).

Just as they had hypothesized, women with a lifetime history of eating disorders were more likely to have experienced physical IPV during the perinatal period (but not the postnatal) period and more likely to report emotional IPV. Rates of IVP were high: physical violence affected from 9.6% to 14.0% of women, while the incidence of emotional violence was even higher, up to 28%.

YouTube: Striking Back at Pro-ana Communities

A Finnish group used a hi-tech approach to evaluate pro- and anti-pro-ana video viewers.

Reprinted from Eating Disorders Review
January/February Volume 27, Number 1
©2016 IAEDP

Pro-anorexia (pro-ana) online communities have aroused concern because they are readily accessible and promote adoption of an illness with high morbidity and mortality. Moreover, they are very frequently visited: for example, in the EU Kids Online survey, 10% of children 9 to 16 years old had viewed such sites (Livingstone et al, London: LSE, 2011).

But, what about the anti-pro-ana online sites and videos? Are they equally effective? Dr. Atte Oksanen and colleagues at two universities in Finland teamed with the Swiss Federal Institute of Technology (ETH Zurich) in Zurich, Switzerland, to study emotional reactions to pro- and anti-pro-ana online content using a technique called sentiment analysis (J Med Internet Res. 2015. 17:e256)

Pro-ana communities are found on various social media sites, including Facebook, YouTube, Twitter, Instagram, Pinterest, and Flickr. YouTube is a social media mega-star that reaches more than 1 billion viewers, and 300 hours of video are uploaded to it every minute. YouTube is also the most popular social media site that uses publicly available videos and comments; thus, its easy availability and popularity make it a significant source for information about anorexia. Dr. Oksanen and colleagues used one of the features of YouTube, the feedback by viewers of videos to either “like” or “dislike” the video or to post a comment in the comment section below the video. Any registered YouTube user can use this function. The authors selected YouTubebecause users commonly engaged in active discussion by expressing either positive or negative sentiments in their messages, so that, for example, anti-pro-anorexia content may challenge pro-ana content. The researchers asked three research questions concerning the characteristics of the pro-anorexia and anti-anorexia videos and video uploaders: the strength of the positive and negative emotional feedback, and whether uploading time or video length was related to comments.

From October 15 to 29, 2014, the authors retrieved YouTube videos by searching two terms, “pro-ana” and “anti pro-ana.” They also used an automatic web crawler using the YouTube Data Application Programming Interface, a technique used to measure video popularity during political campaigns. Video comments were assessed with the SentiStrength automatic sentiment tool, which uses an algorithm to estimate the sentiment content based on a list of approximately 3,000 sentiment words and grammatical categories. 

Anti-pro-anorexia videos were more popular among viewers

The authors collected a large amount of data, including 133 pro-ana videos and 262 anti-pro-ana videos. These 395 videos drew a total of 12,161 comments from 7,903 commenters. Only 1% of viewers commented on both types of videos. Ninety-two percent of the video uploaders were female and the rest qualified themselves as unknown or “other” genders. The viewers came from 13 different countries; 44% came from the US, but the authors reported that the country of origin had no impact on the comments. The two types of videos had more than 6 million total views, and a positive finding was that the anti-pro-ana videos were more popular than the pro-ana videos.

Unlike an earlier Facebook study in which a pro-anorexia group was found to be more active and better organized than an anti-pro-ana group (Eat Weight Disord. 2013. 18:413), in their study the authors found that pro-anti-ana videos were more popular among viewers, received more video “likes,” and were commented upon more positively. The difference between these two studies may be traced to the type of social media examined. YouTube is a publicly available global platform for distributing video content; with Facebook an individual often sets up the group and thus has more power and means to manage what is said and distributed within that group and how it is structured. The content is also commonly available only to those users who join the “group.” In contrast, YouTube material is available to all users and can spread virally to other YouTube users and other social media. 

The results clearly show that the pro-ana community has online opponents, at least within the YouTube community. The anti-pro-ana videos were more popular and produced more positive feedback than did the videos promoting anorexia. Study limitations included the use of only one online community and the fact that all comments analyzed were limited to English. However, the results should be viewed as a source of encouragement in the efforts against pro-ana sites.

UPDATE: Calming Fears of Gaining Excess Weight after Recovery

Reprinted from Eating Disorders Review
January/February Volume 27, Number 1
©2016 IAEDP

Often patients recovering from an eating disorder predict they will become obese over the next decade (“I’m scared I’ll get fat”). Results of a recent follow-up study led by Helen B. Murray and colleagues at Harvard Medical School and Northeastern University, Boston, showed that after 22 years, most former patients had body mass indexes (BMI, kg/m2) in the normal range. The results were reported at the 2015 International Conference on Eating Disorders in Boston, MA. Two cohorts were analyzed: Wave 1, from 1987 to 1991 involved 225 patients followed for 10 years, who had DSM-IV diagnoses of anorexia nervosa and bulimia nervosa. Wave 2 involved 175 of the patients followed from 2011 to 2013. The authors also reported that the rates of change in BMI are faster in the earlier years after recovery, and that short-term changes predict long-term return to normal BMIs. To calm a patient’s fear of excess weight gain after recovery, the authors suggest helping patients focus on long-term results. Learning about normal long- and short-term weight changes will help them have reasonable expectations about their weight.

Improving Coverage for Eating Disorders: A Long, Slow Process

Reprinted from Eating Disorders Review
January/February Volume 27, Number 1
©2016 IAEDP

As Eating Disorders Awareness Week 2016 approaches, a little progress has been made in the effort to improve insurance coverage for patients with eating disorders (see also the May/June 2014 issue of EDR on breaking down barriers to eating disorders treatment).

One bright spot in 2015 was passage of Missouri’s Senate Bill 145, which amended a standing state law by adding a new section relating to the treatment of eating disorders. While other states may have vague laws requiring treatment of eating disorders, Missouri’s is the first state to dictate that treatment for eating disorders must be covered by insurance companies, according to Kerry Dolan, who directs the legal advocacy program of the National Eating Disorders Association.

This action followed a six-year battle to get more comprehensive coverage for eating disorders treatment by recently retired Missouri House Representative Rick Stream. Stream’s daughter Katie died in 1995 after a long battle with bulimia nervosa; her potassium levels were so low that her heart stopped. Citizen advocate Annie Seal worked on the bill for 7 years. 

When Missouri Governor Jay Nixon signed the bill in August last year, Missouri became the first state in the nation to establish specific parameters that insurance companies must follow under the Patient Protection and Affordable Care Act, or ACA. Missouri’s new law is the first in the country to fully define treatment that must be covered according to the “Practice Guideline for the Treatment of Patients with Eating Disorders, adopted by the American Psychiatric Association, which outlines medical and psychological care. It is not a mandate but defines coverage under Missouri’s current mental health parity law. One important portion of the new law is that weight will no longer be used as the sole criterion for approving treatment. It replaces the edict that insurers in the state cover treatment only when an individual reaches 80% of his or her ideal body weight. This percentage has been unhelpful for anorexic patients and more so for those with bulimia nervosa, who can maintain a healthy weight despite being unhealthy.

One Idea: A National Benchmark Plan

Proponents of improved health coverage for patients with eating disorders have endorsed adoption of a national benchmark plan that would address the inequalities currently existing in access to lifesaving treatment for people with eating disorders.

Under the current ACA, 10 states now require coverage for anorexia nervosa and bulimia nervosa on the same basis as other mental healthcare conditions. Eighteen states only require coverage for eating disorder treatment within individual health plans, such as plans for state employees and group health plans. The remaining states have no laws requiring coverage of eating disorders. The ACA also provided three positive steps: (1) people with preexisting conditions can no longer be denied coverage for care. Before this, many insurance companies standardly denied coverage to people with eating disorders, classifying their conditions as preexisting. (2) Patients can remain on their parents’ insurance policies until they reach age 26, which is a real boon since so many cases affect people in their teens and 20s. (3) More people may qualify for Expanded Medicaid (now available in 28 states).

Sarah Hewitt, JD, has proposed that the inequalities in eating disorder coverage can be remedied through the adoption of a national Benchmark system. The Health and Human Services Department declined to define mental health care as an “Essential Health Benefit” (EHB), shifting the burden to the states to set individual benchmarks for care. However, this year they will be required to review this decision, taking into account events and consequences during 2014 and 2015 (Law and Inequality 2013. 31: 411). Attorney Hewitt contends that significantly higher healthcare costs result when insurers delay or refuse coverage to people with eating disorders. 

The case of Danielle Moles illustrates this principle. Long-term care in a residential psychiatric facility was prescribed after Moles was diagnosed with anorexia nervosa. Her eating disorder had progressed, leading to permanent damage to her digestive system, a miscarriage, a stress fracture in one foot and periodic seizures. Her insurer insisted that her treatment was not covered by her policy and only agreed to pay costs after delaying a decision for several years. By the time coverage began, Moles’ condition had significantly worsened. Had coverage began earlier, it was found that her treatment would have cost the insurer roughly $80,000 instead of the $500,000 to $750,000 they eventually paid. The patient estimated that she had spent $150,000 out of packet for her4 care. (Michael Ollove, Parity for Behavioral Health Coverage Delayed by Lack of Federal Rules; http:/www.pewstates.org/projects/stateline/headlines/parity-for-behavioral-health-coverage-delayed-by-lack-of-federal-rules-85899433333) 

Including all DSM-5 Recognized Eating Disorders

One step the Department of Health and Human Services could take would be to include all DSM-5 recognized eating disorders, including ED-NOS, into the category of “mental illness” in the EHB. As Hewitt indicates, such a national benchmark would finally guarantee that sufferers of all types of eating disorders received coverage for the long-term and comprehensive care needed for their recovery.

(Note: At the 2016 iaedp Symposium on Amelia Island, FL, Los Angeles-based attorney and eating disorders advocate Lisa S. Kantor, Esq. will present a preconference training session on “Advocating for Patients in the Current Legal and Regulatory Landscape.” The session is scheduled on February 17, from 9am to 12 noon.)

Masculine Norms and Internalization of Body Ideals on Body Image

Lina Ricciardelli, School of PsychologyDeakin University, Australia

Increasingly during the last 10 years, researchers and clinicians have noted the importance that men place on their body image. While many view this as a new phenomenon, the evidence shows that body ideals for men have been valued throughout the centuries and since ancient times (Ricciardelli & Williams, 2012). The main and current body ideal for men in Western cultures is leanness and muscularity but thinness, attractiveness, youthfulness, and fitness are also valued. On the other hand, Eastern cultures traditionally place less importance on the physical body and a higher value on the pursuit of intelligence, justice, purity and celibacy, integrity, and courage. However, there is some evidence that this is changing as studies have shown that non-European men living in Western countries are more at risk of body image problems, disordered eating, and other related health risks behaviors (Ricciardelli, McCabe, Williams, & Thompson, 2007). These differences may in part reflect the changing status quo and power relations for men and/or the higher level of social isolation of men in minority groups when compared to the dominant cultural group(s). 

Masculine norms and the internalization of body ideals in the media are central sociocultural factors for understanding the importance of body image among men (De Jesus et al., 2015). Masculine norms reflect and reinforce social and cultural expectations for men to conform to particular behaviors and attitudes. In the words of Thompson and Pleck (1986, p. 53) “they prescribe and proscribe what men should feel and do”. Some of the main masculine norms found among men from Western countries such as the US, UK, and Australia, are the pursuit of winning, power over women, and heterosexual self-presentation.  These masculine norms have been found to be related to the internalization of body ideals among men, and typically mirror the content of television and films, where there is an overemphasis on competition and winning, the objectification of women, and an underrepresentation of gay men (De Jesus et al., 2015). Many men internalize these ideals and values, which have then been found to be associated with a higher drive for muscularity and leanness. The drive for muscularity involves a preoccupation with attaining large muscles, whereas the drive for leanness places the focus on attaining a body with well-defined muscles and low fat.

More research is now needed to understand the direction of the above relationships. All the research to date has been cross-sectional so we can not determine whether masculine norms precede or follow internalization of body ideals and body image concerns. Additionally, the majority of studies have been conducted with men who identify as White/European, thus the generalizability of the findings to other ethnic and cultural backgrounds is not possible.

Prevention work is also needed to assist men reject rigid notions of masculinity which highlight the need for power and dominance. The development of broader and healthier notions of masculinity that connect men with other men, family and intimate partners, and that promote rationality, integrity, and free thought, is essential for well-being (de visser & Smith, 2007).

The Attuned Representation of Self (ARMS): 10 Practices for Incorporating Positive Body Image into the Treatment of Eating Disorders

Catherine Cook-Cottone, Ph.D.

Central to each of the Eating Disorders (EDs) is an individual’s relationship to his or her body. That is, the fundamental organizing feature is a disturbance in how the body is experienced, fed, cared for, and accepted. Research has documented a complex etiological course that includes genetic, physiological, familial, and relational influences (Cook-Cottone, 2015a). Central, for many, is the loss of an embodied sense of self (Cook-Cottone, 2015b). Accordingly, along with the other risk factors it is believed that our way of being in today’s culture can lead to risk, and for some disorder. In today’s technological, social media, and image-focused culture, it can be easy to simply ignore, discount, or minimize the importance of the mind and body connection. Through daily implicit an explicit choices, we are all at-risk for travelling down an objectifying pathway upon which an attuned mind and body connection can be lost. Once we are on this path, engagement with the body occurs within the framework of its role in the creation of a manufactured image, edited, and engineered to appear attractive according to current ideals (e.g., thinness, leanness, or with Kardashian/Nicki Minaj curves). Within the unremitting flow of social media “likes”, edits, posts, the casual flips through fashion magazine pages, and hours viewing video screens filled with edited and stylized productions, our sense of who we are as embodied beings fades from awareness. Our individual and perhaps collective consciousness shifts. The body and its corporal needs are split apart from the conceptual image of self so many of us are working to manage. Nevertheless, no matter how far we go down the constructed, idealized image path, the body demands to be fed, exercised, nurtured, and integrated into daily life. In this divide, lies the problem and a big part of the answer. 

The split between actual needs and an idealized, manufactured image can become impossible to effectively negotiate. The Attuned Representational Model of Self (ARMS) provides a model for how to get back to a centered, functional, and embodied experience of the self. It is a road map for awareness and self-care (Cook-Cottone, 2015a, 2015b). Attunement and self-care are viewed as forms of self-love. In essence, the ARMS process reflects the caring for oneself in an active practice of loving-kindness. Notably, this shift toward personal ownership of self-care and body appreciation is not new as an approach to eating disorders. You are encouraged to read Kim Chernin’s influential work on eating disorders detailed in, “The Hungry Self: Women, Eating and Identity,” and “The Woman Who Gave Birth to her Mother: Tales of Transformation in Women’s Lives” (Chernin, 1985; 1998). You will see that finding a positive path to recovery that integrates the whole self and involves active self-care has been a long time coming. 

Attuned Representational of Model of Self (ARMS)

According to the ARMS (see Figure 1), the self is an active construction, a representation of the needs and relational dynamics of the inner and outer aspects of living (Cook-Cottone, 2006, 2015a, 2015b). The inner aspects of self include the physiological (i.e., body), the emotional, (i.e., the feeling), and the cognitive (i.e., thinking) domains. The outer aspects of self include the microsystem (i.e., family and close friends), exosystem (i.e., community), and macrosystem (i.e., culture).  How individuals perceive and experience their bodies involves an ongoing interaction among the aspects of self (Cook-Cottone, 2015b; Wood-Barcalow et al., 2010). The two self-systems (i.e., internal and external) are interconnected by attunement and self-care (Cook-Cottone, 2006). Based on Daniel Siegel’s work in the field of interpersonal neurobiology, attunement is defined as a reciprocal process of mutual influence and co-regulation (Siegel, 1999, 2007). The active construction of the self in shown in the center. (See Figure 1) It is the embodiment of the ongoing behavioral patterns that create and maintain attunement within an individual’s inner and outer lives (Cook-Cottone, 2015a, 2015b). As illustrated by the ARMs, effective functioning of the self goes beyond self as subject or object (Cook-Cottone, 2015b). Healthy, embodied self-regulation occurs when an individual is able to maintain an awareness and maintenance of the needs of the inner aspects of self (i.e., physiological, emotional, and cognitive), while engaging effectively within the context of family, community, and culture (see Cook-Cottone, 2006, 2015a, 2015b; Seligman, 2011). See Cook-Cottone (2006, 2015a; 2015b) for detailed explanations of the internal and external influences that lead to and maintain eating disorders. 

Figure 1: The Attuned Representational Model of Self.
Adapted from Cook-Cottone, 2006, 2015a, 2015b

In the case of eating disorder risk, influences from the internal system (i.e., cognitive, emotional, and physiological) and/or the external system (i.e., family, community, or culture) individual, collectively, and/or cumulatively contribute to misattunement and self-care, which fails to develop or is disrupted (e.g., Marcus & Levine, 2004; Cook-Cottone, 2006, 2015a, 2015b). In deference to external pressures and ideals, those at risk may objectify, invalidate, or see the internal aspects of the authentic, inner self as unacceptable (Cook-Cottone, 2006, 2015a, 2015b; Tylka & Augustus-Horvath, 2011). When missattunement, objectification, and invalidation occur, the authentic, inner self is often abandoned or ignored (Reindl, 2002; Tiggemann & Williams 2012). The disordered representational self is constructed to regain, at least affectedly, the individual’s attunement with his or her external, ecological context (Cook-Cottone, 2006; Cook-Cottone, 2015a, 2015b; Reindl, 2002; Tiggemann & Williams 2012; See Figure 2: The Disordered Representational Self). The internal aspects of self (i.e., thoughts, feelings, and physiological needs) are left without representation through action or voice (Chernin, 1985; Cook-Cottone 2015a). Eating disordered behaviors, thoughts, and motivations take on a critical role in the organization and functioning of the self. The internal aspects of self become attuned to the experience of eating disorder symptoms in a self-perpetuating, self-reinforcing disorder (Cook-Cottone, 2006). As a tangible symbol of the self, the body becomes something to control, change, and bring into alignment with cultural or media ideals. In chronic, clinical cases, the eating disorder becomes the central organizing feature of the individual’s life, his or her identity (e.g., Arnold, 2004; Cook-Cottone, 2006; Cook-Cottone, 2015a, 2015b; Reindl, 2002).

Figure 2: The Disordered Representational Self.Adapted from Cook-Cottone, 2006, 2015a, 2015b

A Solutogenic Approach to Eating Disorders

Taking a salutogenic approach, patients can work on their symptoms, relationships, and coping, as well as strive toward a life that positive psychologists would describe as flourishing (Cook-Cottone, 2015b; Keys, 2007; Seligman, 2011; Tylka, 2012). Full recovery, or flourishing, is viewed as an awareness of, and commitment to, an attuned inner and outer life in which internal needs are met and the external demands are negotiated without compromise to physical or mental health (Cook-Cottone, 2006, 2015a, 2015b; Keys, 2007; Seligman, 2011). For many years, treatment providers have appropriately focused on the physical, cognitive behavioral, and familial aspects of treatment. These approaches often include body image work to reduce body dissatisfaction and distorted body image (see Cash, 2008). From the solutogenic perspective, future directions in ED treatments can build on current treatment models that focus on reducing symptoms and move toward the possibility of creating a positive, healthy, and thriving relationship with the body (Cook-Cottone, 2015b). 

Distinctly, the ARMS approach holds that those struggling with disordered eating can hope for a recovery that is more than a battle to avoid symptoms and tolerate, or ignore, what they perceive as their less-than-perfect bodies (Antonovsky, 1978; Cook-Cottone, 2015b; Frisen & Holmqvist, 2010; Seligman, 2011; Wood-Barclow, Tylka, & Augustus-Horvath, 2010). As an augmentation to traditional therapeutic goals, individuals with EDs can work to nurture a healthy relationship with the body through the development of positive body image and an active practice of self-care (Cook-Cottone 2015b). Further, there is no to need to wait until eating and body-related symptoms have remediated, as safe, positive practices, embracing a positive body image and self-care can begin during any phase of treatment. For more on the framework for a salutogenic approach to flourishing and well-being, see Keys (2007) and Seligman (2011).

What is Positive Body Image? 

According to the experts, positive body image features: inner positivity, body appreciation, body acceptance and love, a broad conceptualization of beauty, and active filtering of information in a body protective manner, and respect for the body (see Avalos, Tylka, & Wood-Barcalow, 2005; Tylka, 2012; Wood-Barcalow et al., 2010). A growing field of research has shown that positive body image is distinct from body dissatisfaction and is uniquely associated with well-being (Avalos et al., 2005; Tylka, 2012; Tylka & Wood-Barcalow, 2015). It is important to acknowledge that to those who are struggling with eating disorders and a strong, negative body image, the idea of a positive body image can seem unrealistically ambitious (Cook-Cottone, 2015b). The gap between what the patient is feeling in the current moment and where the therapist would like them to be can feel too large. Patients need to have an embodied experience of a winnable gap. It is critical to follow a process that allows positive body image to be experienced as accessible and possible. That is, the process must be broken down into small, actionable steps. Further, given the medical risk inherent in eating disorder symptoms, it is important to focus on body image within the context of supporting a patient’s ability to self-regulate, address life-threatening eating disordered behaviors, and increase effectiveness within his or her relationships and environment (Cook-Cottone, 2015b).

Growing toward a healthy embodied self involves active engagement that goes beyond rather than thinking about the body differently (Cook-Cottone, 2015b). As first explicated in the article, “Incorporating Positive Body Image into the Treatment of Eating Disorders:  A Model for Attunement and Mindful Self-Care,” moving a patient toward flourishing is a two-step process (Cook-Cottone, 2015b). Flourishing requires both awareness and action. That is, the flourishing inherent in positive body image necessitates the embodiment of two ways of being: (a) having an awareness of the internal and external aspects of self, and (b) engaging in mindful self-care (Cook-Cottone, 2015b). Mindful self-care behaviors bring awareness and commitment to action and attitude matters. Within the context of mindful self-care, patients attend to the needs of the self with loving-kindness (Cook-Cottone, 2015a). For patients in recovery, this requires a shift from negative, judgmental, over concern with the body toward a stance of loving self-care that honors the inherent need for mind and body connection. In this way, recovery is filled with self-compassion and an appreciation for the living, breathing, functioning physical self (Cook-Cottone, 2006, 2015a, 2015b; Keys, 2007; Tylka, 2012; Tylka, Russell, & Neal, 2015). In the ARMS method, patients are coached to use self-care tools to both protect the self from stress and unhealthy external standards and demands, as well as to assess and choose environmental conditions that enhance well-being and intentionally engage in health promoting behaviors (e.g., intuitive eating, exercise, and yoga; Cook-Cottone et al., 2013; Cook-Cottone, 2015a, 2015b). 

From Eating Disorder to Flourishing: Embodiment of Attunement and Self-Care

It is important to reinforce engagement in sound treatment that includes a team with training and experience treating individuals with eating disorders (i.e., a medical doctor, nutritionist, and mental health professional; Cook-Cottone 2105b) and that the patient is receiving the appropriate level of care (i.e., outpatient, day treatment, or inpatient care). By adding the ARMS approach, there are several practices that can help cultivate an inner and outer attunement that facilitates an appreciation and care for the body, as well as supports the body’s role in the environment (i.e., functions). These self-care tools bolster inner strength and promote resilience (Cook-Cottone, 2015b). The 10 practices are listed here as a short review. For an extended discussion with empirical support for each practice see Cook-Cottone (2015b). 

Practice #1: Body Acceptance

Body acceptance and love involves a comfort with the body exactly as it is (Frisén & Holmqvist, 2010; Tylka, 2012). It involves an attunement of the inner aspects of self (i.e., thought, feelings, and body) via cultivation of a cognitive schema for the body that accepts all shapes, sizes, and unique qualities, as well as an emotional valance of loving-kindness toward the body (Cook-Cottone, 2015b). In this way of viewing the body, it is understood that no one can be perfect and that pursuit of this “illusory ideal” can be physically and mentally harmful (Tylka, 2012, p. 659; Wood-Barcalow et al., 2010). For a wonderful “in treatment” approach use Thomas Cash’s (2008) book, The Body Image Workbook: An Eight-Step Program for Learning to Like Your Looks. The text begins with a set of assessments that can help bring patients to an awareness of their body image challenges. 

Practice #2: Body Appreciation

Body appreciation is the practice of gratitude for the function, health, and aspects of the body (Tylka, 2012: Frisen & Holmqvist, 2010; Wood-Barcalow et al., 2010). Reflecting attunement between the body and its role in the environment, the body is valued for its inherent strengths and its ability to function within the environment rather than its appearance (Frisen & Holmqvist, 2010). This includes thinking about and focusing on the body, and noticing and praising the body for what it is able to do rather than critiquing its appearance (e.g., “My arms are so strong;” Tylka, 2012; Tylka & Augustus-Horvath 2011). At the cognitive and emotional levels, there is an appreciation of all shapes and sizes, ethnicities, skins tones, types and shades of hair, skin art, scars, mobility, disability, and genetic differences (Cook-Cottone, 2015b). 

Practice #3: Self-Compassion

According to Neff (2003), self-compassion is the practice of responding to challenges and personal threats by treating oneself with nonjudgmental understanding and kindness, acknowledging distress, and realizing that pain and struggle are part of the universal human experience. Helping create attunement among the inner aspects of self, self-compassion practice involves a cognitive reframing of challenge and threat as well as an emotional shift toward loving-kindness rather than frustration or fear. Self-compassion has been found to buffer the associations from media-thinness related pressure to disordered eating and thin ideal internalization (see Tylka, Russell, & Neal, 2015). 

Practice #4: Spirituality 

Spirituality can play a substantial role in positive body image. It is theorized that those with positive body image hold a belief that there is a higher power, or an order in the universe, that accepts them unconditionally (Tylka, 2012). Spirituality integrates each of the internal aspects of self (i.e., the thinking, feeling, and physical) through passionately held beliefs and active practices (Cook-Cottone, 2015b). The body is seen as a temple for the spiritual self that must be maintained and cared for in order for an individual’s spiritual life to flourish (Tylka, 2012). 

Practice #5: Addressing Basic Physical Needs

In contrast to making choices based on appearance or unrealistic external ideals or standards, health promoting self-care behaviors support positive body image (Wood-Barcalow et al., 2010). This involves listening to the body’s needs and choosing behaviors based on the needs of the body (Cook-Cottone, 2015b). These practices help to bolster a connection with the inner aspects of self and include addressing basic physical needs (i.e., medical care, nutrition, and hydration), exercise for health and enjoyment, and adaptive methods for stress relief and body care (Cook-Cottone, 2015b).

Practice #6: Intuitive Eating

In early to middle recovery, intuitive eating may be more aspirational as the patient works to adhere to meal plans and reconnect with his or her body (Cook-Cottone, 2015b). Clinically, a meal plan offers the patient safety and security from the possible indecision and ambiguity that can be associated with intuitive eating (Cook-Cottone, 2015b). Intuitive eating can be presented as a possibility once those with EDs are able to detect their hunger and satiety cues (Tribole & Resch, 2012). It is important to know that there, quite possibly, can be a time when eating is enjoyable, connected to the body’s needs and wants, and involves a trust in the body for knowing what it needs. 

Practice #7: Healthy Exercise

Research has emerged that suggests that exercise for health and enjoyment may be associated with positive body image (Frisen & Holmqvist, 2010). For example, adolescents with high levels of body satisfaction tend to view exercise as a natural and important part of life, as joyful, and health promoting (Frisen & Holmqvist, 2010). How one exercises matters. It is important to note individuals with positive body image do not tend to describe exercise as a way to lose weight or control the size or shape of the body and that they slow down or rest when they need to (Wood-Barcalow et al., 2010). Further, having health-related, rather than appearance-focused reasons for exercise may be protective (Homan & Tylka, 2014; O’Hara, Cox, & Amorose, 2014) and help. Calogero and Pedrotty (2004) found that mindful exercise improved outcomes for those with AN. Yogic approaches may be especially beneficial for those with eating disorders (e.g., Carei, Fyfe-Johnson, Beuner, & Brown, 2010; Cook-Cottone, 2015a; Cook-Cottone, Beck, & Kane, 2008; Klein & Cook-Cottone, 2013). 

Practice #8: Appreciating the Function of the Body

Appreciating the body for its functions rather than its appearance can be protective (Cook-Cottone & Phelps, 2003). Physical self-esteem, or feeling good about what your body can accomplish is inversely related to body dissatisfaction, or being dissatisfied with the size and shape of your body (Cook-Cottone & Phelps, 2003). 

Practice #9: Actively Filter Messages

The ability to filter messages from others and the media in a body protective manner may be associated with maintenance of a positive body image (Tylka, 2012; Wood-Barcalow et al., 2010). Those with a positive body image seem to have a cognitive filter that screens information to determine if it is accepted or rejected (Tylka, 2012; Wood-Barcalow et al., 2010). Information that is assessed as negative or harmful to body image is rejected (e.g., weight-related comments; photo-shopped or idealized images of beauty, femininity, and masculinity). According to Tylka (2012), this process includes the affirmation that filtering information in this way creates more time and energy to focus on the important aspects of life. 

Practice #10: Body Positive Friends

Those who have a positive body image secure and maintain relationships with individuals who unconditionally accept their bodies and the bodies of others and do not hold an idealized version of the body as important (Cook-Cottone, 2015b). Specifically, those with a positive body image maintain friendships with others who are accepting of themselves (Wood-Barcalow et al., 2010). Within the context of these relationships, an individual feels valued and loved based on his or her inner qualities such as creativity, personality, and intellect (Tylka, 2012). Further, in body positive relationships, appearance is not frequently mentioned (Frisen & Holmqvist, 2010). If appearance is mentioned, it is related to the creative, interchangeable aspects (e.g., clothes, jewelry, or hairstyle; Tylka, 2012). 

Conclusions

Cultivating mental health goes beyond ameliorating symptoms and asks for more than languishing (Keys, 2007; Seligman, 2011). For those struggling with eating disorders, flourishing and well-being should be considered as possibilities (Cook-Cottone, 2015b). This includes engaging in mind and body attunement and effective, mindful self-care while negotiating environmental demands and supports. The ARMS approach posits that positive body image can play a powerful role in the treatment of eating disorders as patients go beyond traditional therapeutic goals to nurture a healthy relationship with the body and others (Cook-Cottone, 2015b). Through awareness and active practice, patients recovering from eating disorders can potentially experience positive body image along with mental and physical health. They can flourish. 

For more on positive body image and self-care see the full article in Cook-Cottone, (2015b).  Further, see Mindfulness and Yoga for Self-Regulation: A Primer for Mental Health Professionals (Cook-Cottone, 2015a) for a detailed description of the Mindful Self-Care Scale.

Toward a More Inclusive Understanding of the Body Image Construct: Findings from Studies with Black Women: The Role of the Media in Body Image and Eating Disorders

By Christina M. Capodilupo, Ph.D. , Ed.M.

Content analyses reveal that the size of women appearing in virtually all media outlets has decreased significantly since the 1960s, becoming even more prominent in the 1970s simultaneous with an explosion of reported eating disorder cases. This circumstantial evidence suggested to researchers that there may be a relationship between mass media exposure and eating disorders. Because the majority of reported cases were White girls and women, and because mainstream media images predominantly depicted a White thin ideal, researchers and theorists made two major (and related) assumptions: (a) eating disorders are diseases that afflict mostly White women; and (b) thin media images of White women inform the weight and shape concerns that underlie the various behavioral aspects of eating disorders. There is ample research to suggest that White women internalize the thin ideal through mainstream media exposure and that this internalization contributes to negative feelings about one’s body as well as eating disorder symptoms.

 Though there are many studies that investigate the role of media in body dissatisfaction among White women, there is a dearth of studies that look at the role of the media on Black women’s body image. Among the handful of studies that do exist, Black women are often asked about mainstream TV viewing or pressures to conform to the thin ideal, and in the majority of those studies, Black girls and women appear to be unaffected by said images. There are, however, a few recent studies that support the relationship between internalizing thin body ideals and disordered eating symptomology for Black women. These studies include racial identity as a moderating variable and suggest that women who are more White-identified are more susceptible to internalizing images of thinness and experiencing subsequent eating disorder symptoms. Women for whom race (Black) and ethnicity (African American, Caribbean American, etc.) are more salient are found to be unaffected by thin media. A substantial amount of research suggests that thinness does not necessarily represent a body ideal for many women in this population.

The Thin Ideal Is Not a Universal Ideal

Research within the last two decades has found that body image and eating patterns differ among African American and White girls and women. Specifically, findings tend to suggest that African American girls and women: (a) do not ascribe to the same thin ideal; (b) do not endorse the same high levels of body dissatisfaction; (c) are generally more satisfied with their appearance; and (d) engage in less eating disorder behavior when compared to their White counterparts. When specifically looking at media studies, qualitative work suggests that Black adolescents and women reject thin-ideal images as: irrelevant, not representative of their ideal, and unimportant to themselves and others in the Black community. Experimental designs have shown media images of Black women to have significant effects on the self and body esteem of African American females while images of White women have no effect. Social comparison theory asserts that comparisons are made to like others (those who are more similar on relevant attributes), so images of thin White women are unlikely to be considered a like other to many Black females. Thus, Black women are likely to reject the White mainstream media ideal as a valid source of comparison and instead compare themselves to images of other Black women. Perhaps this accounts for the lack of significant findings in those studies that assess Black women’s body dissatisfaction after viewing media images of White women. 

A prevailing perspective regarding body image differences between White and Black women involves the differing body size preferences between the two cultures. There is a substantial body of work to support the notion that both female and male members of the African American community prefer larger body sizes (accomplished through figure scale studies, waist hip ratio calculations, etc.). Yet, there are very few studies which investigate the implications of this distinct body ideal. Instead, even though the literature suggests that such a pursuit is not relevant or meaningful for many African American women, most studies on body image with this population have continued to incorporate the thin ideal into their research design. 

Reviewing the literature as a whole, it would appear that African American women are protected from body and eating disturbances. However, the methods by which these conclusions have been reached are based on quantitative investigations which utilize body image measures that centralize the thin ideal. In these studies, even when White samples are not explicitly included, African American women are being implicitly compared to their White counterparts for whom drive for thinness and preoccupation with weight and shape have proven to be salient. What about African American women and Black women for whom thinness is not relevant? Are we to believe that this group is protected from negative feelings about their physical appearance because they are not concerned with the thin ideal?

A Culturally Relevant Body Ideal

Ample sociocultural and historical sources support the idea that skin tone and color, hair length and texture, and facial features represent appearance characteristics that are salient to the body image of Black women. Despite this, very few empirical studies have investigated the effect that these particular beauty ideals have on African American women’s feelings about their physical appearance. The vast majority of work that includes these appearance attributes as part of Black women’s body image is qualitative. This small body of work, conducted with both undergraduate and community samples, shares the following findings with regard to body image: (a) hair and skin are important aspects, (b) a large backside, small waist, and large breasts and thighs are idealized, (c) being thick and toned is idealized, and (d) Black men’s appearance preferences are influential. These studies also suggest that Black women are not immune from negative feelings about their physical appearance just by virtue of their race. Instead, they are just as vulnerable to body image disturbance when their cultural body ideals are considered.

A Media Theory Tested

My specific research began with a grounded theory analysis of Black women’s body image. The theory generated in this study produced a core category of Body/Self Image, defined by physique, hair, skin, and attitude, which was both negatively and positively affected by Interpersonal Influences (i.e., the influence of Black men and family members), and was negatively affected by Experiences of Oppression (i.e., racism/sexism and invisibility) and Media Images (i.e., influence on Black Men and lack of acknowledgement of Afrocentric features). Figure 1 depicts these relationships. Specifically, our study found that hair, skin, and attitude were equally as important as weight and shape in the core category of body/self image for our participants.  Our participants also perceived Black men’s aesthetic preferences to very much include hair texture and length, skin tone and complexion, and facial features.

Figure 1. Conceptual model of the generated theory. The core category of Body/Self Image, as defined by hair, skin, attitude, and physique, is affected by Interpersonal Influences (category 2) from Black men and family members, Experiences of Oppression (category 3) due to race/gender microaggressions and feelings of invisibility, and Media Images (category 4) that influence Black men’s aesthetic preferences and lack an acknowledgement of Afrocentric features. The relationships between the categories are denoted by solid and/or dashed arrows that indicate qualitatively positive or negative effects, respectively. Media images, particularly their influence on Black men, play an integral role in linking categories to each other as does feelings of invisibility in impacting participants’ body and self image.

With regard to the media, participants spoke about believing the media to have a powerful effect on influencing Black men’s aesthetic preferences. Not only did this produce interpersonal pressures to meet these standards, but they were also perceived as oppressive, which then negatively affected participants’ feelings about their physical appearance. Notably, this nuanced finding not discussed in other qualitative reports suggests that these images are not simply directly harmful to body image through Black women’s internalization of them, but are also indirectly through their perceived influence on Black men. This phenomenon is indicative of the “third person effect,” whereby the perceived influence of media images on others is more powerful than the effect of the images on the self. Participants in this study expressed concern that the media’s admiration of Afrocentric features (e.g., full lips and backsides) on White female models/celebrities and Eurocentric features (e.g., thinness and lighter skin tone) on Black female models/celebrities would influence Black men to prefer mainstream ideals of beauty that increasingly diverged from Black women’s body image. This divergence not only contributed to participants’ described feelings of devaluation but also negatively impacted their body image; that is, the more participants felt that Black men’s preferences were influenced by the media, the more they felt negatively about their physical attractiveness. In a follow up study, we supported these relationships and the theory through structural equation modeling. 

Conclusion

Findings in the larger body of work that looks at racial differences in body image and eating disorders have led researchers to conclude that strong ties to a Black or African American identity protects or buffers Black women from body dissatisfaction and eating disorder symptoms. However, our work suggests that Black women who are strongly identified with Black culture are equally as vulnerable to appearance dissatisfaction when culturally relevant variables are integrated into the study design. This work underscores the idea that psychological constructs (i.e., body image) are not necessarily universal constructs, and instead may represent the values of the dominant culture. As clinicians and researchers, our job has become to challenge accepted truths such as these and start from the ground up when working with a population that has not been previously represented in the literature.