Cognitive-behavioral roots of body image therapy and

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COGNITIVE-BEHAVIORAL ROOTS OF BODY IMAGE THERAPY AND PREVENTION 1 Cognitive-behavioral roots of body image therapy and prevention Helena Lewis-Smith, Phillippa Diedrichs, & Emma Halliwell Centre for Appearance Research, University of the West of England, UK. COGNITIVE-BEHAVIORAL ROOTS OF BODY IMAGE THERAPY AND PREVENTION 2 Highlights  Cash’s cognitive behavioral model is the foundation for many interventions.  Cash was the pioneer of self-directed CBT programs for body image.  Researchers have developed CBT programs of different formats for different groups.  Cash’s model informed cognitive dissonance, media literacy, and third-wave programs.  Contemporary positive body image interventions have built upon Cash’s model. COGNITIVE-BEHAVIORAL ROOTS OF BODY IMAGE THERAPY AND PREVENTION 3 Abstract The existing array of evidence-based body image prevention and intervention approaches has evolved over time. However, the majority originated directly or indirectly from a cognitive- behavioral conceptualisation of body image pioneered by Thomas F. Cash. In this way, it is difficult to overstate the impact Tom Cash has had on body image intervention research and practice. His ground-breaking work, building on the work of Schilder and Fisher, was the first to provide a comprehensive model of body image that reflected the broad range of influences and consequences of body image. His differentiation of the components of body image as a construct and between body image traits and states allowed us to identify and influence targets for intervention. Moreover, the intervention strategies that Tom Cash employed are still used today and laid the foundations for contemporary intervention programs. There is a gap of more than 15 years between the first and last of us receiving our PhDs, yet Cash’s work has been an important influence on us all. We are extremely grateful for the theoretical and practical tools that he has given to our field. In this paper, we will outline how Cash’s work has informed contemporary body image intervention and prevention. We will describe Cash’s theory and intervention tools before discussing how this work paved the way for subsequent research and practice. COGNITIVE-BEHAVIORAL ROOTS OF BODY IMAGE THERAPY AND PREVENTION 4 1. Introduction Evidence-based body image prevention and intervention approaches have evolved significantly. Many interventions have originated directly or indirectly from a cognitive- behavioral conceptualisation of body image pioneered by Thomas F. Cash. Tom Cash has therefore had an enormous impact on body image intervention research and practice. His ground-breaking work on cognitive-behavioural approaches to addressing body image, which extended the work of Schilder and Fisher, provided the first comprehensive theoretical model of body image, including its influences and consequences. His identification of state and trait components of body image facilitated the identification of targets for intervention. The intervention strategies that Tom Cash conceptualised are still used today and have laid the foundations for many contemporary intervention approaches. This paper provides an overview of Thomas F. Cash’s pivotal work in the development of cognitive behavioral therapy (CBT) interventions to address body image concerns, and how this work has laid the foundation for the development of other intervention and prevention approaches. We begin by introducing Cash’s cognitive behavioral theoretical model of body image. Then, we discuss his research developing self- directed CBT programs targeting components in his model and how other researchers have developed similar CBT programs in different formats for different groups. Next, we consider more contemporary intervention strategies that target components comprised in Cash’s model and have received empirical support, including cognitive dissonance, media literacy, and third-wave CBT approaches. Finally, we discuss the more recent move to intervention strategies focusing on positive body image, which build on Cash’s earlier work and offer promise for the prevention field. 2. Cash’s Cognitive-Behavioral Model of Body Image COGNITIVE-BEHAVIORAL ROOTS OF BODY IMAGE THERAPY AND PREVENTION 5 Cash (2002, 2012) conceptualised a theoretical cognitive-behavioral model of body image, which captures various inter-related factors. He proposed and differentiated historical factors and proximal or concurrent factors that shape the development of body image attitudes, comprising ‘body image evaluation’ and ‘body image investment’ (see Figure 1). Body image evaluation reflects an individual’s beliefs and appraisals (e.g., satisfaction or dissatisfaction) regarding their body. This is distinct from body image investment, which refers to the cognitive, behavioral, and emotional importance of an individual’s body in relation to their sense of self-worth. The proposed historical and proximal factors have subsequently constituted targets for many different intervention approaches, which will be discussed later. Historical factors in the model pertain to earlier events, experiences, and characteristics that influence an individual’s thoughts, feelings, and behaviors in relation to their body (Cash, 2002, 2012). These include cultural socialization, interpersonal experiences, physical characteristics and changes, and personality aspects. Cultural socialization refers to the messages conveyed, primarily via media (e.g., television, social media, adverts), which dictate and reinforce cultural “standards” and norms relating to physical attractiveness. In addition to media, expectations and opinions concerning cultural beauty norms are also conveyed via interactions with family, friends, and others. These may be conveyed directly, through making well-meaning and critical comments about one’s appearance, and also indirectly, for example, via parental role modelling. Physical characteristics are also a key factor in shaping body image, whereby the extent to which one’s appearance matches with cultural norms of physical attractiveness can influence body image, leaving individuals with less culturally valued physical characteristics (e.g., higher body weight, acne, grey hair) more vulnerable. Finally, personality also plays a role in the development of body image. Whilst certain traits (e.g., perfectionism, self-objectification, COGNITIVE-BEHAVIORAL ROOTS OF BODY IMAGE THERAPY AND PREVENTION 6 endorsement of traditional gender attitudes) may increase the risk for body image concerns, others (e.g., strong self-concept, high self-esteem) may foster resilience and promote positive body image. Proximal factors in the cognitive-behavioral model refer to present life events, which comprise precipitating and maintaining influences on body image experiences. These include information processing and internal dialogues, body image emotions, and coping and self- regulatory actions. It is postulated that specific events or situational cues (e.g., body exposure, social scrutiny, changes in appearance) activate schema-driven processing of information relating to, and self-evaluations of, one’s appearance. Individuals with self- schemas relating to appearance (i.e., with higher levels of body image investment) pay more attention to and preferentially process information pertinent to their appearance. The subsequent internal dialogues (referred to as “private body talk”) constitute emotional automatic thoughts and interpretations about one’s appearance. Among individuals with problematic appearance self-schemas and body image attitudes, the thought processes and internal dialogues may reflect faulty cognitive distortions, such as overgeneralization, dichotomous thinking, biased social comparisons, and magnification of perceived defects. To cope with distressing thoughts and emotions relating to one’s body, individuals engage in a range of well-learned strategies and behaviors. Adjustive reactions to perceived environmental events may consist of body checking, avoidant or body-hiding behaviors, seeking social reassurance, or compensatory strategies. These behaviors and strategies may temporarily relieve body image distress, however, they reinforce this distress in the long- term. 3. Cognitive Behavioral Therapy COGNITIVE-BEHAVIORAL ROOTS OF BODY IMAGE THERAPY AND PREVENTION 7 Tackling key factors conceptualised within the cognitive behavioral model of body image, cognitive behavioral therapy (CBT) is one of the most researched and empirically supported interventions to address body image concerns. The aim of CBT is to modify irrational and dysfunctional thoughts, emotions, and behaviors, through techniques such as self-monitoring, cognitive restructuring, psychoeducation, desensitization, and exposure and response prevention. Cash and colleagues were among the first researchers to develop and evaluate CBT programs to address body image concerns. In 1987, Butters and Cash conducted a randomised controlled trial to evaluate a therapist-administered 6-session one-to- one structured CBT program among university women with body image concerns in the United States. The program consisted of psychoeducation concerning the causes, prevalence and effects of body dissatisfaction; relaxation training; desensitization (e.g., mirror exposure); self-monitoring; (i.e., antecedent events, beliefs, consequences); identification and correction of cognitive body image errors; engaging in body-related behaviors for sense of mastery or pleasure; stress-inoculation techniques; and relapse-prevention strategies. The program effectively decreased body dissatisfaction, preoccupation with appearance, and body image- related avoidance, with improvements remaining two months later (Butters & Cash, 1987). Following this, Cash published an audio-recorded CBT program, Body-image therapy: A program for self-directed change, to be used in self-directed and therapist guided formats (Cash, 1991). The program comprised 11 sessions, and included self-assessment of historical, cultural, physical, and interpersonal influences on body image; self-monitoring of body image experiences (i.e., ABCs: antecedent events, mediating cognitions, and emotional and behavioral consequences); relaxation training; desensitization (e.g., mirror exposure); identification and cognitive restructuring of cognitive body image errors; self-assessment of avoidant and compulsive body image behaviors and strategies (e.g., exposure, response prevention, stress inoculation) to reduce these; using problem-solving and assertion to COGNITIVE-BEHAVIORAL ROOTS OF BODY IMAGE THERAPY AND PREVENTION 8 manage difficult interpersonal events; and relapse-prevention strategies. Grant and Cash (1995) compared two different ways of administering the program among body-dissatisfied young women: self-directed with modest therapist contact (weekly 20-minute meetings) versus therapist-delivered group therapy (weekly 90-minute sessions). Equivalent effects were found for both modalities, with improvements observed in body satisfaction, body image affect and thoughts, investment in appearance, preoccupation with appearance, and body image-related avoidance. In addition to the audio-recorded CBT program, Cash developed a 10-week, 8-step, self-help CBT book, What do you see when you look in the mirror? Helping yourself to a positive body image (Cash, 1995), which was nearly identical in content. Cash and Lavallee (1997) evaluated the self-help book among body dissatisfied university women, who only encountered professional contact in weekly 10-minute calls with the research assistant to discuss compliance. The minimal-contact program attained equivalent effects to both conditions explored by Grant and Cash (1995), indicating the efficacy of self-help CBT programs with minimal therapist contact to address body image concerns. As a result of this evidence, in 1997, Cash published a refinement to his self-help CBT book, and titled it ‘The body image workbook: An 8-step program for learning to like your looks’. This was updated a decade later (Cash, 2008). Table 1 displays the content for both editions of the workbook. Whilst Cash’s CBT program has not undergone evaluation in its entirety, two studies explored the effectiveness of self-administered selected components. Firstly, Strachan and Cash (2002) randomised university women and men experiencing body image distress to either a combination of psychoeducation and self-monitoring (reflecting steps 1 and 2 of the program), or a combination of these components with the addition of strategies for COGNITIVE-BEHAVIORAL ROOTS OF BODY IMAGE THERAPY AND PREVENTION 9 identifying and modifying faulty body-image cognitions (i.e., cognitive restructuring; reflecting steps 4 and 5 of the program). The interventions lasted six weeks, within which there was no face-to-face therapist support. Findings indicated that the combination of psychoeducation and self-monitoring was equally effective in improving body dissatisfaction, body image investment, and body image-related emotion, as the combination plus the addition of cognitive restructuring. Strachan and Cash (2002) noted lower compliance with the additional cognitive components, compared with studies evaluating other CBT programs (including self-administered programs) with at least modest therapist input. This suggests that a therapist may be necessary to facilitate the more demanding components of CBT, such as cognitive restructuring. Based on these findings, Cash and Hrabosky (2003) tested a 3-week program comprising psychoeducation and self-monitoring with greater therapist contact (i.e., weekly meetings to administer instructions and exchanging of materials), which attained similar improvements in body image, and additional reductions in eating pathology. Further, attrition rates were lower (14%) compared with the 53% attrition rate in the previous evaluative study (Strachan & Cash, 2002), further emphasising the importance of therapist involvement for reinforcing participants’ adherence and progress. Since Cash’s promising start to developing CBT programs to improve body image, other researchers have developed CBT programs employing different formats and targeting different groups. Indeed, whilst Cash had primarily focused on self-directed CBT programs evaluated among university women, Rosen and colleagues evaluated therapist-delivered group-based CBT programs among this group (e.g., Rosen, Cado, Silberg, Srebnik, & Wendt, 1990; Rosen, Saltzberg, & Srebnik, 1989), demonstrating improvements on body image compared with a control group up to three months later. Further, a therapist-delivered individual CBT program was found to significantly improve shape concern among women relative to a relaxation control group; with effects lasting up to three months (Shafran, Farrell, COGNITIVE-BEHAVIORAL ROOTS OF BODY IMAGE THERAPY AND PREVENTION 10 Lee, & Fairburn, 2009). The benefits of CBT on body image have also been extended to women in midlife. When compared with a waitlist control group, group-based CBT programs have been found to improve body image among women in midlife (Smith, Wolfe, & Laframboise, 2001), with one program attaining lasting effects on multiple measures of body image and eating pathology up to six months later (McLean, Paxton, & Wertheim, 2011). An online CBT program has also been developed and evaluated by a group of researchers (Celio et al., 2000; Winzelberg et al., 2000; Zabinski, Wilfley, Calfas, Winzelberg, & Taylor, 2004). Student Bodies is an 8-week structured CBT intervention, with the addition of an online moderated discussion group. Participants are sent weekly emails to encourage them to participate in the next session. Once logged in, the individuals are provided with weekly online content, and are invited to complete associated activities, such as self-monitoring, writing in their journal, or participating in the online discussion group; which is moderated by a psychologist. A randomized controlled trial evaluating Student Bodies was conducted among more than 400 women (Mage = 20.8) at increased risk for developing an eating disorder in the US (Taylor et al., 2006). In comparison with the waitlist control group, intervention participants experienced significant reductions in weight and shape concerns for up to one year later. Further, subgroups of women with either baseline compensatory behaviors (e.g., laxative use, self-induced vomiting) or higher baseline body mass index (BMI) reported a decrease in the onset of eating disorders. Other researchers (Chithambo & Huey, 2017) also developed an online CBT program; primarily derived from content comprising The Body Image Workbook (Cash, 1997). In four online sessions, participants engage in several activities, such as recognising alternative and rational interpretations of irrational thoughts. A randomised controlled trial evaluating the program supported its efficacy in reducing body dissatisfaction, eating pathology, internalization, and depression, among US women (Mage = 20.9); when compared with the control group COGNITIVE-BEHAVIORAL ROOTS OF BODY IMAGE THERAPY AND PREVENTION 11 (Chithambo & Huey, 2017). Collectively, these findings indicate promise for Internet-based CBT programs, which are less costly and have the potential for greater scalability. CBT programs have also been developed for individuals with a visible difference, defined as an altered appearance, or one considered different from the ‘norm.’ However, they tend to have been evaluated with less rigour and have demonstrated less promising findings (Bessell & Moss, 2007). Nonetheless, more CBT-based programs are undergoing development. For example, several psychologist-delivered group-based CBT programs have demonstrated efficacy in improving body image among individuals with appearance changes resulting from treatment for breast cancer (e.g., Lewis-Smith, Diedrichs, & Harcourt, 2018; Sebastián, Manos, Bueno, & Mateos, 2007). Further, researchers have developed Face IT, a self-administered CBT-based online intervention with minimal therapist input targeting adults with any form of visible difference. A randomised controlled trial found similar improvements in body image in the computer-based program compared with a face-to-face version of the intervention, with both attaining greater improvements relative to the control group (Bessell et al., 2012). A modification of the online program is being developed for adolescents and has demonstrated promise (Williamson, Griffiths, & Harcourt, 2015). Overall, two meta-analytic reviews have supported the efficacy of CBT (Cash & Smolak, 2011; Farrell, Shafran, & Lee, 2006). In 2005, Jarry and Ip conducted a meta- analysis to review the effectiveness of 19 standalone-CBT programs for body image concerns. Overall, they found a large, positive effect on body image (d+ = 1.00). Changes were found in the behavioral, evaluative (i.e., satisfaction), and perceptual aspects of body image. Jarry and Ip (2005) concluded therapist-assisted programs to be more effective than self-directed programs. Further, a meta-analysis of change techniques employed in body image interventions found that interventions comprising CBT-based techniques were associated with larger effects on body image, compared with other strategies such as self- COGNITIVE-BEHAVIORAL ROOTS OF BODY IMAGE THERAPY AND PREVENTION 12 esteem enhancement exercises and discussing physical activity (Alleva, Sheeran, Webb, Martijn, & Miles, 2015). These techniques included discussing the role of cognitions in body image, teaching monitoring and restructuring of cognitions, and incorporating guided imagery, exposure, and size-estimate exercises. Interestingly, Jarry and Ip’s (2005) earlier meta-analysis noted the smallest improvements in the investment dimension of body image, compared with body satisfaction and behavioral components. It was proposed that whilst CBT is equipped to effectively challenge the manifestations of high body image investment, it may be less equipped to tackle its underlying idiosyncratic processes. Jarry and Ip (2005) suggested this may be due to these individuals still being heavily overinvested in their appearance. Further, whilst CBT demonstrates potential to improve body image among certain groups (e.g., those with eating pathology; Rosen, Reiter, & Orosan, 1995), the therapeutic model may not always be easily translatable to non-clinical settings (e.g., in schools). 4. Cognitive Dissonance CBT programs represent the body image interventions that are most strongly rooted in the cognitive behavioral model of body image. However, Cash’s (2002, 2012) model also laid the foundation for the development of other eating disorder prevention strategies and for programs that are disseminated in non-clinical settings. One effective technique is the induction of cognitive dissonance, which is based on the theory that holding cognitions inconsistent with one’s behavior evokes psychological discomfort, motivating the individual to change their attitudes and cognitions to match their behavior to restore consistency (Festinger, 1957). The Body Project (Stice & Presnell, 2007), one of the most efficacious eating disorder prevention programs (Watson et al., 2016), is based on cognitive dissonance. In this program, dissonance around appearance-related beliefs and behaviors is achieved by COGNITIVE-BEHAVIORAL ROOTS OF BODY IMAGE THERAPY AND PREVENTION 13 encouraging individuals to engage in counter-attitudinal exercises, whereby they are required to critique and speak out against the thin-ideal of beauty. This results in dissonance, as the individual who internalizes the thin-ideal is acting in a way which is inconsistent with their beliefs. This putatively leads to a shift in attitude towards the new perspective to relieve discomfort. This then is thought to lead to reduced internalization of the thin-ideal, which theoretically, in turn, should result in decreases in body dissatisfaction, dieting, and eating pathology (Stice, 2001; Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999), given its role as a widely recognised risk factor for these outcomes among females (Jackson & Chen, 2011; Rodgers, McLean, & Paxton, 2015; Stice, 2002; Stice & Whitenton, 2002) and males (Hausenblas et al., 2013; Jackson & Chen, 2011). Cognitive dissonance approaches primarily focus on attitude change. Specific activities of cognitive dissonance-based interventions target, and can be mapped onto, Cash’s social-cognitive model. For example, the Body Project directly targets cultural socialization, a historical influence, in addition to thin-ideal internalization, an aspect of body image investment. It includes activities that discuss the role of activators (e.g., appearance ideals, appearance-related comments), beliefs (e.g., thoughts and interpretations, feeling fat when engaging in social comparison), and emotional and behavioral consequences (e.g., feeling worthless, dieting and exercise behavior). It also directly addresses aspects of cognitive processing, for example, by challenging the relevance of social comparison with appearance ideals in the media. Finally, it encourages behavior change through behavioral challenges, such as going swimming or wearing shorts despite fears of negative evaluation or not meeting appearance ideal standards. Meta-analytic reviews indicate that cognitive dissonance approaches, primarily in the form of the Body Project intervention, are the most effective eating disorder prevention programs for selective samples of girls aged 14 years and above (Stice, Shaw, & Marti, COGNITIVE-BEHAVIORAL ROOTS OF BODY IMAGE THERAPY AND PREVENTION 14 2007). Compared with other intervention approaches, programs employing a cognitive dissonance approach attained larger effects for body dissatisfaction, eating pathology, dietary restraint, and thin-ideal internalization (Becker, Smith, & Ciao, 2006; Stice, Trost, & Chase, 2003), with effects maintained up to three years post-intervention in some cases (e.g., Stice, Marti, Spoor, Presnell, & Shaw, 2008). Indeed, multiple randomised controlled trials have demonstrated the effectiveness of the Body Project and its variations in improving body dissatisfaction, eating pathology, and other risk factors among women at university (18-21 years), when delivered by body image experts or psychologists (Becker, Smith, & Ciao, 2005; Matusek, Wendt, & Wiseman, 2004; Mitchell, Mazzeo, Rausch, & Cooke, 2007; Stice, Mazotti, Weibel, & Agras, 2000). Findings also suggest that the program can be task shifted to clinicians (Stice, Butryn, Rohde, Shaw, & Marti, 2013; Stice, Rohde, Butryn, Shaw, & Marti, 2015; Stice, Rohde, Durant, Shaw, & Wade, 2013; Stice, Rohde, Shaw, & Gau, 2017) and peer leaders (Becker, Bull, Schaumberg, Cauble, & Franco, 2008; Becker et al., 2010; Stice et al., 2013; Stice et al., 2017). Research has also indicated that the Body Project is an effective intervention in the school context. Findings show the program to be beneficial for mid to older adolescent girls (14-17 years), with body image expert or psychologist facilitators delivering improvements in body dissatisfaction, internalization, and eating pathology (Stice et al., 2003, 2008). Further, task shifting delivery of the program to school staff (i.e., nurses, counsellors, teachers; Stice, Rohde, Gau, & Shaw, 2009; Stice, Rohde, Shaw, & Gau, 2011), and older peers (Ciao, Latner, Brown, Ebneter, & Becker, 2015; Halliwell, Jarman, McNamara, Risdon, & Jankowski, 2015) does not dampen its effectiveness, with largest and longest-lasting effects observed when delivered by school staff. Researchers have adapted the Body Project for use with younger adolescent girls (12-13 years); however, evaluations have produced conflicting findings (Halliwell & Diedrichs, 2014; Rohde et al., 2014). Body dissatisfaction was found to COGNITIVE-BEHAVIORAL ROOTS OF BODY IMAGE THERAPY AND PREVENTION 15 have reduced significantly at post-intervention in one study (Halliwell & Diedrichs, 2014), but in another study no improvements were found immediately post-intervention or at follow- up (Rohde et al., 2014), with effect sizes smaller than in other universal trials among older adolescent girls (Stice et al., 2009). This suggests the possibility that dissonance approaches may be less effective for younger girls compared with their older counterparts, or that younger girls may experience less body dissatisfaction. Given the success of cognitive dissonance programs in face-to-face settings, research has explored the potential for task-shifting from in person facilitators to online automated delivery. Chithambo and Huey (2017) created an online cognitive dissonance program, primarily derived from content comprising the Body Project. It consisted of four weekly sessions, with homework assignments in-between. Participants were university women (Mage = 20.9) at elevated risk for developing an eating disorder. Relative to a no-treatment control condition, intervention participants reported significantly greater reductions in body dissatisfaction and internalization at post-intervention. This study provided support for an online cognitive dissonance program relative to a no-treatment control condition; however, it did not provide insight as to how it would perform in comparison to the original in person group-based format, and in the longer-term. Similarly, Stice and colleagues created an online version of the Body Project, known as the eBody Project (Stice et al., 2017). It comprises six 40-minute modules, which include self-education games and activities (such as text role plays). The activities are entirely voluntarily, thus mirroring the group program. A four-arm randomised controlled trial conducted with university women (Mage = 22.2) allocated participants to either a clinician-led Body Project, a peer-led Body Project, or the Internet- based eBody Project. Findings revealed that relative to an educational video control group, participants who completed the eBody Project reported significantly greater reductions in body dissatisfaction and related variables, with improvements in internalization and eating