Article

The importance of the body image in the treatment of eating disorders

Introduction.
Since the late seventies there has been an explosion of literature on the body image of patients with eating disorders. Most of this information concerns the assessment, pathology and development of body image especially of anorexia nervosa ( Bruch, 1962;Garfinkel & Garner, 1984; Smeets, 1997); by contrast little attention has been given to its modification.
This is remarkable, because already in 1984 Vandereycken and Meerman stated that a disturbed body image is a determinant for further progress of the eating disorder. At that time they pleaded for scientific research, in which different therapeutic techniques and methods, aimed at influencing and changing the body image, should be compared.
Freeman, Beach, Davis & Solyom (1985) researched different variables affecting a relapse in bulimia nervosa. They concluded that compared to other variables, body image appears to be among the important prognostic factors for bulimia nervosa. Button (1986) came to the same conclusion for anorexia nervosa.
Also Anita Jansen (1998) wrote that scientific researchers and health -practitioners have become more and more convinced that an eating disorder is the result of a disturbed body image and for that very reason the body image must be treated.

Overview of treament programs
In the past years specific video feedback-methods to assess and treat the body image have been developed. The video-distortion method is a perceptual method which is more and more being used in body image research (Probst, 1997). Subjects are asked to adjust their distorted body image on a monitor until it reflects their actual body size and to indicate their ideal image. Recently, at the Catholic university of Leuven this method has been further developed: instead of a monitor, a life-size screen is used (Probst, Coppenolle &Vandereycken, 1997). The video-distortion method on a life-size screen can be considered a very reliable and useful instrument for the assessment of treatment effects.
The other method is the video-confrontation method. According to a standard procedure, video recordings of the patient are made at the start, halfway through and at the end of the treatment period. The therapeutic value comes from the self-confrontation with the body and from group-members' feedback. The feedback is intended to counter balance the patient's negative cognition of the body as well as to offer a support mechanism resulting from the existence of shared experiences.

Speaking about treatment of the body image, Michel Probst (1997) introduced the term Body-oriented therapies (BOT). BOT comprises all forms of psycho- therapy that focus on the body to improve psychic functioning. This form of treatment is usually connected t to existing psychotherapeutic schools of thought (behaviour, cognitive or psychodynamic therapy).
BOT often involves movement exercises, sports and games, relaxation techniques, guided imagery and role-playing.

Examples of BOT are:
* Body image groups of the psychotherapists Karin Jasper and Sarah Maddocks (1992).
* Body image therapy of Ann Kearney-Cooke and Ruth Striegel-Moore (Garner & Garfinkel,1997).
* Psychomotor therapy described by Vandereycken, Depreitere & Probst (1987).
* A feminist approach of body image therapy developed and described by Marcia Hutchinson(1994).

The above-mentioned examples are from the United States and Belgium.
In the Netherlands, body-oriented therapy is being applied, but it is not well-developed or described as a special treatment program for changing the negative and/or disturbed body image.
In the clinical health care for eating disorders it is the psychomotor therapist who usually applies non-verbal techniques such as: relaxation, movement exercises, sports and games, bodily exploration and expression.
The bodily exploration and expression consist, among other things, of self-confrontationtechniques with video and mirror.The years of experience as a psychomotor therapist working with eating disorder patients gave me the opportunity to develop my own treatment program aimed at changing the body image. The program is designed as a module that can be used both in clinical and outpatient practices. The concept version of this module was published in January 2000, the definitive version will be ready in the beginning of 2001.


OUTLINE OF A TWO-PHASE TREATMENT PROGRAM
The first phase of the treatment uses cognitive-behavioural techniques in combination with self-confrontation techniques with video, mirrors, polaroid-photo's and drawings of the body. The cognitive body-image therapy of Anita Jansen (1998) inspired me to make use of exposure methods with clothing.

In the second phase there is a shift to a more psychodynamic form of treatment, in which the body and the body image become, rather than object of treatment, medium of treatment. The focus is on exercises from the Pesso-motor therapy, guided imagery and psychodrama.

Target group
Patients with eating disorders

* Anorexia nervosa
* Bulimia nervosa
* Binge-eating disorder

Indicators
Indicators
* Disturbed body image and/or negative body image
* Obsession with eating and weight
* Obvious fluctuations in weight in the history of the patient
* Continuously busy with taking measures against gaining weight, such as being on a diet
and/or vomiting, using laxatives, exercising excessively.


Contra-indicator
* Body Mass Index higher than 30


Goals of therapy

General
* Realistic perception of the own body
* Acceptance of the own body
* Endurance of the own body

Specific
* Learning to focus on the body as a whole instead of its individual components
* Neutralising the negative cognition of the own body
* Learning to look at the own body in a mirror and on video
* Getting accustomed to the changes of the own body
* Becoming re-aware of physical and emotional feelings

Measurable
* Patient has a lower score on The Body Attitude Test (BAT) (Probst, Vandereycken,
Coppenolle, Vanderlinden, 1995)
* Patient has a higher score on the "Lichaamswaarderingslijst" this is a Dutch
adaptation of the body-cathexis-scale of Secord and Jourard (Baardman & Jong, 1984)
* Verbal reactions of the patient to the video images during the video-confrontation
method (written down or recorded)


Activities
The treatment can be broken down in two types of activities

Activities where the body is the object of treatment
* Exposure exercises with clothing
* difficult and/or different
* feminine or masculine
* less covered
* different colours
* different style
* Mirror exercises (immobile and dynamic)
* Video (immobile and dynamic)
* Photographs
* Polaroid pictures during the treatment
* Snap shots of the past
* Slides of how women are portrait in the media and in other cultures
* Drawings of the body, which compares perception, desire and reality
* Breathing and relaxation exercises

Activities where the body serves as a medium of treatment
The significance and the function of the (disturbed) body image can be investigated and
interpreted in this matter.
* Exercises from the Pesso-motor therapy
* Guided imagery
* Role-playing (psychodrama)
* Bioenergetics



Therapeutic attitude
First phase
Coaching and modelling attitude

Second phase
Directive and confronting attitude


Structure of the therapeutic session
Contents
* Exposure exercises with clothing (20-30 minutes)
* Activity
* Closing (minimal 10 minutes)

Length
* Group session clinical: 90 minutes
* Group session out-patient: 120 minutes
* Individually: 45 -60 minutes

Frequency
* Group: weekly
* Individual: weekly or once in the two weeks


Total length of the therapy: Maximum one year


LITERATURE

* Baardman, I. , Jong de, J.G. (1984). Het meten van de lichaamswaardering. Bewegen &Hulpverlening, 1,1, 28-41.
* Broekens, A (1997). 'Verborgen schoonheid' in beeld door 'schijf van vijf'. Scriptieter afsluiting van het eerste jaar van de opleiding Integratieve Bewegingstherapie.
* Bruch, H. (1962). Perceptual and conceptual disturbances in anorexia nervosa.Psychosomatic Medicine, 24, 187-194
* Button, E. (1986). Body size perception and response to outpatient treatment inanorexia nervosa. International Journal of eating disorders, 5, 617-629
* Freeman, R.J., Beach, B., Davis, R., Solyom, L. (1985). The prediction of relapse inbulimia nervosa. Journal of psychiatric Research, 19, 349-353
* Garfinkel, P.E., Garner, D.M. (1984). Perceptions of the body in anorexia nervosa. InK.M. Pirke & D. Ploog (Eds.), The psychobiology of anorexia nervosa. Berlin: SpringerVerlag.
* Garner, D.M., Garfinkel, P.E. (1997). Handbook of Treatment for Eating Disorders(second ed.) New York: The Guilford Press.
* Hutchinson, M.G. (1994). Imagining Ourselves Whole. A feminist approach to treatingbody image disorders. In: Fallon, P., Katzman, M.A., Woolley, S.C. (eds), feministic
perspectives on eating disorders, (pp.157-168). New York: The Guilford Press.
* Jansen, A. (1998). Lichaamsbeeldtherapie. In: Jansen, A., Meyboom, A. (eds),Behandelingsstrategieën bij bulimia nervosa, (pp72-83). Houten/Diegem: Bohn Stafleu vanLoghum.
* Jansen, A.(1996). Bulimia nervosa effectief behandelen. Een handleiding voortherapeuten. Lisse: Swets & Zeitlinger.
* Jasper, K., Maddocks, S.E. (1992). Body Image Groups. In: Harper-Giuffre,H.,RoyMackenzie, K.(eds), Group Psychotherapy for Eating Dis- orders, (pp.181-199).Washington D.C.: American Psychiatric Press Inc.
* McFarland, B., Baker-Baumann, T.L. (1990). Shame and Body Image. In: Culture and theCompulsive Eater, (pp.77-180). Florida, Deerfield Beach: Health Communications, Inc.
* Probst, M. (1997). Body experience in eating disorder patients. Kortenberg: UniversityCenter Sint Jozef,
* Probst, M., Coppenolle, H. van, Vandereycken, W. (1997). De videovervormingsmethode opgrootbeeldscherm: onderzoeksresultaten bij patiënten met eetstoornissen. Bewegen &Hulpverlening, 14, (4): 250-267.
* Rekkers, M.E. (1998). Psychomotorische therapie met boulimiacliënten: confronterend ofsteunend? In: Verslag studiedag: Bewegingsexpressie-therapie en eetstoornissen,(pp.36-41). Tilburg: Fontys Hogescholen, Dansacademie.
* Rekkers, M.E. (2000). Lichaamsbeleving voor cliënten met eetstoornissen.Psychomotorische therapie module.
* Smeets, M.(1997). Het lichaamsbeeld bij anorexia nervosa: gestoord beeld of gestoordeperceptie? Bewegen & Hulpverlening, 14 , 175-184.
* Vandereycken, W., Meermann, R. (1984). Anorexia nervosa: A Clinican's Guide toTreatment. New York: Walter de Gruyter.
* Vandereycken, W., Depreitere, L., Probst, M. (1987). Body-Orientated Therapy forAnorexia Nervosa Patients. American Journal of Psychotherapy, april, pp. 252-259.