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BEHAVIOR IrU~RAPY20, 393-404, 1989

Cognitive Behavior Therapy for Negative Body Image


JAMES C . ROSEN

ELAYNE SALTZBERG

DEBRA SREBNIK

Umverstty of Vermont

Subjects were twenty-three normal weight women with disturbed body image, but without
eating disorders, who were randomly assigned to either cogmtive behavior therapy or
mmimal treatment. Treatment was provided for six-weeks in a small group format.
Cognitive behavior therapy focused on correction of size and weight overestimation,
modtficauon of distorted and negative thoughts about physical appearance, and ex-
posure to sttuations which provoke thoughts about appearance, i.e., treatment dealt
with perceptual, cognitive, and behavioral aspects of body image disturbance. The
minimal treatment condttion controlled for information and attention. At posttreat-
ment and follow-up, subjects in cognitive behavior therapy showed greater improve-
ments in size overestimation, body dissatisfaction, and behavioral avoidance, com-
pared to subjects in minimal treatment. The results indicate that cognitive behavior
therapy is an effective intervention for disturbed body image m young women.

The adoration of exceeding thinness as a mark of female beauty is evident


in the epidemic of body dissatisfaction (Fallon & Rosin, 1985) and weight losing
attempts among young women and girls (Rosen & Gross, 1987). Reflecting
upon this phenomenon, Rodin and her colleagues aptly referred to women's
preoccupation with weight and shape as a "normative discontent" (Rodin, Sil-
berstein, & Striegel-Moore, 1985). Clearly, negative body image is not limited
to women with eating disorders.
On the basis of its extremely high prevalence alone, negative body image
in women is a problem in need of treatment. There are other reasons, as well,
to develop effective methods to modify negative body image. Extremely nega-
tive body image is distressing, it can interfere with daily functioning and it
has been reported to be associated with depression, social introversion, anxiety,
and negative self-esteem (Noles, Cash, & Winstead, 1985). Further, negative
body image is a core feature of eating disorders. Abnormal eating behavior
and attitudes in these disorders may even be secondary to overconcern about
weight and shape (Fairburn & Garner, 1986). In light of evidence that dis-

Correspondence and requests for reprints should be sent to James C. Rosen, Department of
Psychology, University of Vermont, Burhngton, VT 05405.

393 0005-7894/89/0393-040451.00/0
Copyright 1989 by Assoclauon for Advancementof Behavior Therapy
All rights of reproduction m any form reserved.
394 ROSEN, SALTZBERG, SREBNIK

turbed body image predicts treatment response and relapse, modification of


these concerns may be necessary for a full recovery from eating disorders (Cash,
& Brown, 1987). Although unrelated to the purpose of this study, effective
treatments for negative body image could also be useful for individuals who
are impaired by psychological reactions to physical deformities.
In their review o f the literature, Garner and Garfinkel (1981) proposed that
negative body image in eating disorders is manifested in two ways. One is per-
ceptual distortion of size, or specifically, the tendency to perceive body parts
as unrealistically large. A second manifestation is a cognitive or affective dis-
turbance involving extreme disparagement or irrational aggrandizement o f
the body. To this two-factor conceptualization, we propose that disturbed body
image is also accompanied by behavioral responses. In relation to the present
study, examples o f the behavioral manifestation o f negative body image in-
clude avoiding revealing clothes and dressing to disguise ones shape and weight,
avoiding social situations which may call attention to ones physical appear-
ance, restraining food intake, weighing more often, etc. Body image is a mul-
tidimensional phenomenon and modification o f body image disturbance may
be most effective if attention is given to all three aspects.
To date, there has been little investigation, only two controlled experimental
studies, of how to modify negative body image. Dworkin and Kerr (1987) com-
pared the effect e f cognitive modification, cognitive behavior modification,
and a nondirective control condition on a measure of body satisfaction in col-
lege women. The cognitive modification condition involved rehearsal of posi-
tive and more rational self-statements about physical appearance. In the cog-
nitive behavior modification condition, subjects were to reward themselves for
rehearsal of the self-statements. At posttreatment, subjects in all three condi-
tions reported more body satisfaction than subjects in a no-treatment condi-
tion. The cognitive modification condition was superior to the cognitive
behavior modification and nondirective conditions. Surprisingly, cognitive be-
havior modification was equivalent to the nondirective control. This could
have been due to the extremely superficial treatment, only three one-half hour
sessions, and the weak behavioral component within their cognitive behavior
modification condition. Another limitation of the study was the lack o f a
follow-up assessment.
A more extensive investigation was conducted by Butters and Cash (1987)
in which treatment subjects received six sessions of cognitive behavior therapy
that included relaxation, desensitization to a hierarchy of disturbing body parts,
cognitive restructuring, and assignments to engage in pleasurable physical ac-
tivities. At posttreatment, treated subjects were significantly improved on a
battery of body image measures compared to a waiting list control condition.
Treatment gains were maintained at follow-up, although no comparison with
a control condition was performed at that time.
The present study dealt with some limitations o f these two studies. First,
the experimental design was extended to include a comparison o f cognitive
behavior therapy with a control condition at follow-up. This was necessary
to determine whether the effects of treatment are superior to a control condi-
tion after treatment is withdrawn. Second, our control condition was a min-
CBT F O R N E G A T I V E B O D Y IMAGE 395

imal treatment which provided the subjects with therapy, but without the
specific ingredients of cognitive behavior therapy that are thought to account
for its efficacy. This type of control was needed because Dworkin and Kerr's
results (1987) suggested that cognitive behavior therapy may be equivalent to
a nondirective control condition. In addition, we designed a treatment which
included modifying behaviors related to negative body image so that our model
included perceptual, cognitive, and behavioral components.

METHOD
Subjects
Potential subjects were recruited in two ways. (a) Twenty-seven female col-
lege undergraduates volunteered in response to advertisements posted around
campus for a treatment to improve body image. (b) One hundred and sixty-
two female Introductory Psychology students completed a screening question-
naire focusing on body image for course credit. Out of these individuals, an
overwhelming majority of 151 women expressed interest in receiving treatment.
The subject eligibility criteria were as follows:
(a) Within the normal weight range, as determined by the Metropolitan Life
InsuranCe Height and Weight Charts 0983). Weight was assessed in person
by the experimenters.
(b) Free of a past history of, or present eating disorder. (We felt that it was
inappropriate to offer this circumscribed treatment to women with eating dis-
orders.) Past history of eating disorder was assessed in the screening question-
naire by asking subjects if they had ever been diagnosed or received treatment
for anorexia nervosa or bulimia nervosa. The presence of an eating disorder
was screened with weight data and the Bulimia Test (BULIT) (Smith & Thelen,
1984) plus additional items to cover the DSM-III-R (American Psychiatric
Association, 1987) criteria for bulimia nervosa that pertain to binge-eating
and extreme weight control behavior. Subjects who preliminarily appeared
to be free of an eating disorder (i.e., subjects who were of normal weight and
denied habitual binge-eating, purging, or extreme dieting on the screening ques-
tionnaire) were also given a personal interview that employed the operational
guidelines suggested by Fairburn (1987) to corroborate the reported absence
of bulimia nervosa symptoms on the screening questionnaire.. The final deter-
mination of the absence of an eating disorder was based on the interview.
(c) A score on the Body Shape Questionnaire (Cooper, Taylor, Cooper, &
Fairburn, 1987) which indicated significant negative body image. The cutoff
score was 109 which is at one standard deviation above the mean for a com-
munity sample and at the mean score of a sample of weight and shape preoc-
cupied women. The Body Shape Questionnaire is a self-report questionnaire
that measures body dissatisfaction, fear of fatness, feelings of low self-worth
because of appearance, and desire to lose weight. The questionnaire is cor-
related with other measures of body satisfaction and drive to thinness and
it can discriminate normal from clinical groups (Cooper, et al., 1987).
The following volunteers were screened out: 8 were obese, 9 met the criteria
for bulimia nervosa, 1 had a past history of anorexia nervosa, and 97 had
396 ROSEN, SALTZBERG, SREBNIK

low Body Shape Questionnaire scores. O f the remaining eligible volunteers,


23 individuals were still interested in treatment and available to meet at the
scheduled times. In summary, the participants exhibited significant concerns
about shape and weight, however, none were obese, anorexic or engaged in
regular binge-eating and extreme weight control behavior. The average age
o f subjects was 19.0 years (SD = 1.15) and their average deviation from normal
weight was - 2 . 2 6 percent (SD = 7.77).
Measures
To measure the perceptual component of body image, each subject estimated
the size o f her bust, waist, hips, & abdomen with moveable markers on a table.
Subjects were then measured for actual size with calipers. Size distortion was
calculated as the percent of over- or underestimation o f size, relative to actual
size, for all four body parts combined. Positive numbers indicated an overes-
timation o f body size, and negative values represented an underestimation.
(see Willmuth, Leitenberg, Rosen, Fondacaro, & Gross, 1985). The test-retest
reliability o f this type visual size estimation task was reported to vary from
r = .79 to .96 (Ben-Tovim & Crisp, 1984). With respect to validity o f the mea-
sure, it should be noted that body size distortion in normal weight women
without eating disorders is correlated with body dissatisfaction and drive to
thinness (Cash & Brown, 1987; Willmuth, et al., 1985).
Two questionnaires were used to measure the cognitive-evaluation aspect
o f body image. One was the Body Shape Questionnaire (Cooper, et al., 1987)
which was described previously. The other was the Body Dissatisfaction Scale
o f the Eating Disorders Inventory (Garner, Olmsted, & Polivy, 1983) which
measures satisfaction with body parts, particularly stomach, thighs, buttocks,
and hips. Extensive evidence in support o f the internal consistency and va-
lidity of this scale has been reported (Garner, et al., 1983) and the test-retest
reliability is high (Wear & Pratz, 1987).
The measure o f behavioral avoidance was a 19-item self-report body image
behavior questionnaire that described situations that are typically avoided by
women who feel dissatisfied with their weight or shape. Examples are avoiding
exercise, avoiding social outings with friends where weight might be discussed
or where men might "check them out", avoiding physical intimacy with
boyfriends, avoiding shopping for clothes, wearing baggy clothes instead o f
more revealing and tight fitting clothes, eating less, and weighing more often.
Subjects rated the extent to which they avoid these situations. In a prior study
(Rosen, Saltzberg, & Srebnik, 1988) 1, the test-retest reliability was r = .89,
internal consistency was r = .87, and concurrent validity with the Body Shape
Questionnaire was r = .74. The questionnaire also discriminated normal
women from women with bulimia nervosa.
Procedure
Subjects signed a consent form and were randomly assigned to one o f two
conditions. Thirteen women were in the cognitive behavior therapy condition

I Copies of the questionnaire may be obtained from the authors.


CBT F O R N E G A T I V E B O D Y IMAGE 397

and ten women participated in the minimal treatment control condition. There
were no drop-outs. Subjects met in small groups consisting of the therapist
and three or four subjects. In cognitive behavior therapy there were three groups
with three subjects and one with four, there were two groups with three and
one with four in minimal treatment. Each therapist led both types of treat-
ment groups.
The therapists were a senior undergraduate psychology major and a first
year clinical psychology graduate student. Both were women. Treatment was
standardized for the therapist by using treatment manuals. These contained
session plans with complete lectures, therapeutic exercises, homework assign-
ments and lists of typical therapist-subject verbal exchanges with suggested
responses for the therapist.
The following steps were taken to secure compliance with the treatment
procedures. Each session was reviewed in supervision with a clinical psychol-
ogist. The therapists wrote down verbalizations made by the subjects in re-
sponse to structured exercises in the sessions. The ensuing verbal exchanges
between the therapist and client were evaluated and responses for the ther-
apist to employ in the next session were rehearsed. If necessary, deviations
from the standard treatment format were corrected. In the cognitive behavior
therapy condition which included homework, forms for each of the assign-
ments were checked by the therapist to insure that the subjects completed them.
There were six treatment sessions, each lasted two-hours. Assessment was
done before and after the treatment as well as at two months posttreatment by
someone other than the therapist. Subjects in the two conditions did not differ
significantlyin age or weight deviation. After the second session, subjects com-
pleted a credibility rating of the extent to which they expected to improve by
the end of the program. The means of these ratings for the two conditions
were equivalent.
Cognitive behavior therapy. Session one involved a mini-lecture and dis-
cussion on the definition of body image, its dew.lopment and its effects on
self-esteem and on other aspects of psychological and behavioral functioning.
The concept of size perception was introduced and subjects were asked to
specify the distressing physical aspects of their weight and shape.
In session two, subjects performed a size estimation exercise which used
the same apparatus as described in the Measures section above. In this situa-
tion, however, only the body parts which evoked the greatest distress in sub-
jects were selected for practice. The body parts used in the therapy exercise
were not necessarily the same ones assessed in the outcome measure. For ex-
ample, most subjects were trained in correct estimation of the size of their
thighs, but thighs were not included in the dependent variable. The therapy
exercise involved having the subjects repeatedly estimate the size of the dis-
tressing body part(s) until they could do so accurately.
An exercise related to weight perception involved having the subjects esti-
mate their weight percentiles relative to a normal distribution. These estimates
were then compared with actual weight norms for age and height using the
National Center for Health Statistics norms (1979). Subjects also compared their
weight to the Metropolitan Life Insurance Company Height and Weight Charts
398 ROSEN, SALTZBERG, SREBNIK

(1983). Typically they greatly overestimated their deviation from average weight,
and their attention was drawn to the fact that they erroneously perceived them-
selves to be heavier relative to normal than they really were. Subjects then esti-
mated the weight deviation of three friends whose body size they preferred.
For homework, subjects asked these friends for their actual heights and weights.
These statistics were then compared with norms in the next session. Most often
the subjects weighed relatively less than their friends.
The purpose of these two exercises was to help the subjects recognize that
they were not as large as they first believed, were average or below average
weight, and were about the same size or even smaller than peers whom they
believed looked ideal.
Cognitive modification was the focus of sessions three and four. In a mini-
lecture, the concepts of automatic and irrational beliefs, counter-arguments,
rational thoughts, and positive self-statements were presented. Subjects were
encouraged to get in touch with what they thought about their appearance,
especially body shape and weight and to write these on a self-monitoring chart.
Typically, the thought content related to beliefs that they looked disgusting,
gross, fat, or unattractive to other people and that others evaluated them based
on their appearance primarily or exclusively. Also typical were thoughts that
being thin was the only important aspect of their self-image, that other per-
sonal attributes did not mean as much, and that if they were not exceedingly
thin, it proved they were weak, lazy, unlovable, and incompetent. These thoughts
were processed and evaluated with respect to their accuracy and logic. More
positive thoughts were developed to substitute for the negative thoughts. The
homework was to practice verbalizing self-enhancing statements and to com-
plete the remainder of a four column chart (situation, automatic thoughts,
counterarguments, rational beliefs) (Beck & Emery, 1985). In the fourth ses-
sion, subjects practiced the steps of stress-inoculation (Meichenbaum, 1977)
including rehearsing the more adaptive thoughts while they imagined them-
selves encountering situations which typically provoked the negative automatic
thoughts.
Beginning with a mini-lecture on the self-limiting lifestyle which they de-
veloped around their negative body image, sessions five andsix were designed
to modify behavioral avoidance. Subjects were asked to choose two situations
that they tended to avoid when feeling or thinking negatively about their ap-
pearance, e.g., wearing a tight outfit to school or eating dessert, and to predict
what would happen or how they would feel if exposed to each situation. In
addition to the situation, on a self-monitoring sheet, the subjects wrote down
rational beliefs to substitute for negative predictions (Beck & Emery, 1985).
For homework, subjects practiced exposure to the situations while rehearsing
the more positive thoughts. In the last session, plans were made for the sub-
jects to continue with their behavioral exposure during the next two weeks.
In addition, relapse prevention was discussed and subjects rehearsed thoughts
they could use to handle high-risk situations (Marlatt & Gordon, 1985).
Minimal treatment. The minimal treatment condition paralleled the struc-
ture of the cognitive behavior therapy condition: two sessions were devoted
to size perception, two to evaluative aspects of body image, and two to be-
CBT FOR NEGATIVE BODY IMAGE 399

havioral effects. The length of sessions was the same. The same mini-lectures
and information on body image were provided. Also, subjects were asked to
report how they perceived their shape and weight (perception), what thoughts
they or other people had about them owing to their physical appearance (cog-
nition), and what impact their body image had on activities (behavior). The
difference between the conditions was the absence of structured exercises to
deal with these problems in the minimal treatment. The following elements
from cognitive behavior therapy were excluded in the minimal treatment: ex-
ercises for altering perception, challenging of irrational thoughts or cognitive
restructuring, cognitive self-monitoring forms, and assignments for behavioral
exposure. This condition was designed to provide the subjects with therapeutic
attention, the belief that the subjects were getting an effective treatment, the
expectation for improvement, but without the specific ingredients of cogni-
tive behavior therapy that are thought to account for its efficacy.

RESULTS
Means and standard deviations on the body image measures are presented
in Table 1. Changes in body image as a result of treatment were first analyzed
for all dependent variables combined in a 3 (time) by 2 (treatment) within/be-
tween multivariate analysis of variance (MANOVA). Of greatest interest was
a significant time by treatment interaction, F (8,82) = 7.84, p < .0001 (Hotel-
ling's T 2 criterion). Subsequently, separate 3 (time) by 2 (treatment) univar-
iate analyses for the four dependent variables were derived from the MANOVA.
The criterion for significance was the averaged univariate tests of significance.
The time by treatment interactions were significant for all of the dependent
variables: size overestimation, F (2,20) = 6.67, p = .004; Body Shape Ques-
tionnaire, F (2,20) = 5.94, p = .005; Body Dissatisfaction Scale, F (2,20) =
5.23, p = .009; and reports of behavioral avoidance, F (2,20) = 12.49, p <
.0001. These results indicate that the treatment conditions differed in their de-
gree of change in body image over time.
To further investigate the meaning of these significant interactions, tests of
simple effects were conducted using Hotelling's T 2 statistic for equality of means
with the probability level set at p < .05. These were done between group at
each level of time and within group for each level of treatment. In the event
of a significant within group simple effect for time, further post-hoc compar-
isons were conducted using Newman Keuls tests for differences within group
from pre- to posttreatment, pretreatment to follow-up, and posttreatment to
follow-up, with the probability level set at p < .05. These results are also
presented in Table 1. According to the tests of simple effects, the cognitive
behavior therapy and minimal treatment conditions did not differ from each
other at pretreatment on any dependent variable, however, the between group
differences were significant at posttreatment and follow-up on each measure.
The pretreatment size overestimation for all subjects was comparable to that
of women with anorexia nervosa and bulimia nervosa; also, none of the sub-
jects underestimated their body size at pretreatment. Although size overesti-
mation decreased somewhat for the minimal treatment subjects by follow-up,
400 ROSEN, SALTZBERG, SREBNIK

TABLE 1
MEANS AND STANDARD DEVIATIONS FOR BODY IMAOE MEASURES

Cognitive Behavior Therapy Minimal Treatment Control


Mean SD Mean SD

Size overestimation ( % )
Pre-treatment 22.91 a2 12.38 20.03 a 6.49
Post-treatmenP 4.18 b 9.62 18.84 a 8.79
Follow-up ~ 10.25 b 9.81 15.90a 11.07
Body Shape Questionnaire
Pre-treatment 132.77 a2 13.11 132.60 a2 14.74
Post-treatment ~ 83.69 b 18.80 118 10 ab 22.58
Follow-up' 83.08 b 25.78 105 0 0 b 24.95
Body Dissatisfaction Scale
Pre-t reatment 17.08 a2 4.37 18.10 a2 5.78
Post-treatment' 7.08 b 3.62 13.20b 5.81
Follow-up ~ 6.23 b 4.75 14.50 ab 6.42
Behavioral avoidance
Pre-treatment 4 5 . 9 2 a2 10.26 37.60a 14.10
Post-treatment ~ 29.39 b 5.97 41.90a 11.86
Follow-up ~ 29.08 b 10.36 36.80 a 13.27

Note. Post-hoe Newman Keuls comparisons were done across time (pre to post to follow-up).
Different superscripts (a and b) signify a statistically significant difference at the p < .05
level.
i I n d i c a t e s a significant test of simple effects between groups using Hotelhng's T 2 statistic for
equality of means, p < .05.
I n d i c a t e s a significant test of simple effects within group using Hotelling's T 2 statistic for
equality of means, p < .05

according to the test of simple effects for time, this change was not significant.
Cognitive behavior therapy subjects, however, were significantly more accurate
in estimating their body size after treatment according to the test of simple
effect for time, within group. The Newman Keuls comparisons indicated that
there was a significant decrease in body size overestimation from pre- to post-
treatment and pretreatment to follow-up for the cognitive behavior therapy
participants. In addition, the tests of simple effects between groups indicated
that size overestimation was significantly less for the cognitive behavior therapy
subjects at posttreatment and follow-up. At both assessments after treatment,
the cognitive behavior therapy subjects overestimated within the range of
normal control subjects whereas the minimal treatment subjects remained
within the range of eating disorder patients (Willmuth, et al., 1985).
On the Body Shape Questionnaire, there were significant within group simple
effects tests for time for both conditions, indicating that overall, all subjects
decreased their body dissatisfaction. Post-hoe Newman Keuls comparisons
indicated that the decreases in body dissatisfaction by the cognitive behavior
CBT FOR NEGATIVE BODY IMAGE 401

therapy subjects were significant from pre- to posttreatment and from pretreat-
ment to follow-up. However, the between groups tests of simple effects were
significant at posttreatment and follow-up, indicating that cognitive behavior
therapy subjects showed a greater improvement than the minimal treatment
subjects on this measure. Before treatment, subjects were in the clinical range
on the Body Shape Questionnaire; after treatment and at follow-up the cogni-
tive behavior therapy subjects fell in the normal range on this measure, whereas
minimal treatment subjects remained in the range of weight and shape preoc-
cupied women (Cooper, et al., 1987).
On the Body Dissatisfaction Scale, there were significant within group simple
effects tests for time for both conditions, indicating that all subjects decreased
their body dissatisfaction on this measure as well. According to post-hoe
Newman Keuls comparisons, the cognitive behavior therapy subjects declined
significantly from pre- to posttreatment and from pretreatment to follow-up,
which represented a change from the range of anorexia and bulimia patients
to the normal range (Garner, & Olmsted, 1984; Gross, Rosen, Leitenberg, &
Willmuth, 1986). Post-hoe Newman Keuls comparisons indicated that the de-
crease in body dissatisfaction by the minimal treatment subjects was statisti-
cally significant at from pre- to posttreatment but not from pretreatment to
follow-up. Although the decrease in body dissatisfaction for the minimal treat-
ment subjects at posttreatment was statistically significant, their average score
remained in the clinically severe range. In addition, the simple effects tests be-
tween groups were significant at posttreatment and follow-up, indicating that
the cognitive behavior therapy subjects showed greater change than the min-
imal treatment subjects.
On the behavioral avoidance questionnaire, the tests of simple effects for
time within group were significant for the cognitive behavior therapy subjects,
but not for the minimal treatment subjects. Also, the two conditions were
significantly different from each other at posttreatment and follow-up according
to between group tests of simple effects. Thus, the cognitive behavior therapy
participants reported a decrease in avoiding situations which provoke con-
cern about appearance whereas the minimal treatment subjects did not. Post-
hoc Newman Keuls comparisons across time within the cognitive behavior
therapy condition indicated that the decreases in reported avoidance were
significant from pre- to posttreatment and from pretreatment to follow-up.
Subjects in both groups fell well above the norm on this measure at pretreat-
ment, within the range for bulimia nervosa patients. At posttreatment and
follow-up, the average score for the cognitive behavior therapy condition was
at a normal level (Rosen, et al., 1988).

DISCUSSION
The results of this study show that a six week treatment intervention fo-
cused on body image is effective in improving body image disturbance in col-
lege aged, non-eating disordered women. Cognitive behavior therapy proved
to be more effective than non-directive therapy in producing positive changes
402 ROSEN, SALTZBERO, SREBNIK

in body image. The participants in the cognitive behavior therapy condition im-
proved on all three dimensions (perception, cognition, behavior) of body image
targeted in the treatment. The improvements were clinically significant, as be-
fore treatment subjects scored in the clinical or pathological range on the
measures and after treatment their scores fell to within the normal range. These
changes are quite striking especially considering the short duration of treat-
ment, the modest experience of the therapists, and the fact that treatment was
given in a group format which did not allow for intensive individual attention.
Although subjects in the minimal treatment condition showed mild improve-
ments, their changes were not clinically significant and they improved less in
comparison to the cognitive behavior therapy subjects. Thus, it seems that
education and support alone are not sufficient to improve negative body image
and the benefits of cognitive behavior therapy were not a function of the non-
specific effects of therapeutic attention.
The results of the present study support Butters and Cash's (1987) finding
that cognitive behavior therapy is effective in ameliorating negative body image.
The new finding of this study was that cognitive behavior therapy was supe-
rior to a control therapy at posttreatment and follow-up whereas Butters and
Cash compared cognitive behavior therapy to no treatment and did not test
for group differences at follow-up. The results are both consistent and incon-
sistent with Dworkin and Kerr (1987). Although they also found that cogni-
tive behavior therapy led to improved body image satisfaction, unlike the
present study, their treatment was not superior to a minimal treatment. This
may reflect the superficiality of Dworkin and Kerr's (1987) cognitive behavior
therapy intervention.
There are limitations to these findings. Because the participants in this re-
search were all college women, the generalizability of this program to other
populations is questionable. Body image problems are common in older adult
women and in adolescents, and it would be important to investigate the inter-
vention's effectiveness with these populations. In addition, the generalizability
of the findings would be enhanced with a larger sample size and longer follow-
up period. It would also be important to know if the benefits of this program
extend to other measures of psychological adjustment such as self-esteem and
eating behavior and attitudes.
It is noteworthy that the volunteers for this program did not come from
a usual clinical population. An interesting and important question then is,
did these subjects possess a condition of clinically pathologic proportion or
did they represent a more common condition or "normative discontent" (Rodin,
et al., 1985)? A more comprehensive battery of measures of psychological ad-
justment may give some insights into the comparability of these women to
known clinical groups such as women with eating disorders. Nevertheless, these
subjects were within the range of pathologic body image disturbance on all
measures prior to treatment. Therefore, based on the available data, we be-
lieve their maladjustment was of clinically significant proportions. It may be
that women with disturbed body image separate into comparable subgroups
of those with, and those without the other features of eating disorders, e.g.,
binge-eating and extreme weight control behavior. If true, this raises impor-
CBT FOR NEGATIVE BODY IMAGE 403

tant clinical and theoretical questions regarding the development and manifesta-
tion of eating disorders.
Finally, it should be noted that all four dependent measures were closely
related to the behaviors that were targeted for treatment. For example, self-
statements refuted by the clients during cognitive therapy were similar, in some
instances, to items that were rated on the Body Shape Questionnaire or Body
Dissatisfaction Scale. This link between assessment and treatment is the
hallmark of behavioral assessment of treatment outcome. Because of the close
association, however, it could be argued that the dependent variables were
not completely independent of treatment. At the least, this may be true of
the size estimation outcome measure, because the cognitive behavior therapy
subjects were trained in accurate estimation with the same apparatus that was
used in the assessment, whereas the minimal treatment subjects were not. Even
though the body parts used in the therapy exercise were not the exact ones
that were tested in the assessment (see treatment procedure section), the cog-
nitive behavior therapy subjects may not have decreased their size overestima-
tion to the same extent without this training. We are presently engaged in a
study which will address this question by comparing a cognitive behavior
therapy with and without size estimation training.
Body image dissatisfaction in women is a widespread concern and is linked
with more global psychological adjustment (Noles, et al., 1985). Interventions
to modify negative body image may have widespread applications for the treat-
ment and prevention of eating disorders, in reducing the incidence of unnec-
essary weight reducing behavior, and in improving the psychological adjust-
ment of women. This study has made a contribution in describing a potentially
powerful method to modify body image disturbance.

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RECEIVED; September 8, 1988


FINAL ACCEPTANCE: January 27, 1989