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What's the Best Way to Deal With a Negative Body Image?

Body dysmorphia is almost universal these days. What can be done about it?

Lianne* came to see me for help with her compulsive binge-eating. "I can't stand myself," she said. "I've tried every diet I can think of. I lose weight...and then I gain it all back...and more." Lianne was smart and very funny. She had a successful job and many women friends. But she didn't date and she didn't think any men could possibly be interested her because of her weight. “I’m fat and ugly,” she told me. “Why would a guy even want to talk to me?”

From my perspective, she was neither fat nor ugly but was actually quite attractive. But years of working with, writing and teaching about eating disorders had made me familiar with this contrast between my own perspective and my clients’. Body dysmorphia, or self-criticism for bodily imperfections that seem insignificant to someone else, is a common symptom of eating disorders. In its full blown form, body dysmorphic disorder (BDD) involves an obsessive preoccupation with imagined or slight defects in appearance. This fixation can interfere with a person’s ability to function in the world and can lead to compulsive attempts, such as plastic surgery, to change a minor physical characteristic. In some cases it can lead to suicidal ideation.

Lianne didn’t have BDD, but she did have a distorted image of herself. At one point I asked her to tell me what she thought was wrong with her body. Besides her weight, she said, “and my huge thighs, one eye is smaller than the other. I don’t like my nose, and I have a belly.” When I asked what she liked about herself, she said that she had great skin and hair and that she had a small waist. But like so many other men and women these days, she linked a very specific picture of physical attractiveness with happiness, life contentment, and even intelligence. If she didn’t have the one, she couldn’t have the others.

Why do we do this? Beginning with Susie Orbach’s groundbreaking book Fat is a Feminist Issue in the 1980’s, and moving on to numerous books, articles, blogs and websites today, those of us who work with eating disorders have been fighting an uphill battle to look at these issues more realistically. But we seem to be losing that battle. Instead of there being fewer women with eating disorders, the symptoms of hating one’s body are so common that they are considered practically normal in women, and now in a growing number of men as well! (I’m in the process of co-editing an issue of the Clinical Social Work Journal devoted to eating disorders, and for the first time we have almost as many articles about men as women. I’m not sure that’s a good thing!)

It has been well established that binge eating, purging, dieting and over-exercising can be ways of coping with feelings that can’t be processed. I have listed some of my own and other therapists’ articles about this connection at the end of this post.

Whether or not we have eating disorders or BDD, feelings about our bodies also often represent unspoken and even unthought feelings about our non-physical selves. Thus, “I am fat and ugly” may also mean, “I am feeling selfish,” or “I did something really dumb at work,” or many other self-descriptions.

In our contemporary culture, as sophisticated as we are in so many different ways, we often automatically assume that a slender, delicately built woman with fine features is also a kind, smart, thoughtful and good person. We also believe that she is happy. Similarly, we consider that a physically strong, attractive man must be emotionally solid, dependable, upright and content.

We think that you can judge a book by its cover. But it isn’t true. In my own experience over the years as a psychotherapist, I have certainly seen as many unhappy thin women and fit men as I have overweight or unattractive ones. How is it that we therefore continue to think that physical appearance equals emotional satisfaction?

I don’t claim to have a solution to this cultural problem. It would require changes in the media, in our belief systems, even in the medical profession’s attitudes. Despite studies suggesting that we have gone way overboard in our negative beliefs about weight, we cling to the idea that it is both healthier and superior in all ways to be thin. And we translate that belief to our attitudes towards ourselves and others.

I do know that when clients in therapy become more comfortable with their emotions, they often also become more accepting of their bodies. Interestingly, this shift in self-perception can sometimes lead to small changes in their physical selves. Some clients gain a little weight and others lose a little. They might exercise a little more or, if they have been habitual over-exercisers, they might cut back. They have a more realistic self-image, and to their surprise, they often like themselves better, both physically and emotionally. They are still aware of their own flaws, but they also have a sense of their strengths and positive qualities. And since their bodies no longer represent who they are emotionally, intellectually, or socially, their self-esteem no longer depends on their weight.

This is what happened with Lianne. When she came into therapy, she attributed all of her bad feelings to her weight and what she saw as her other physical flaws. When she was ready to leave therapy, she had become more comfortable with her feelings and, to her surprise, with her body. She actually did lose and keep off a few pounds over the time we worked together, but she realized that the weight loss was far less significant than she had imagined it would be. “What’s really important is that I know what I feel and who I am, and I’m comfortable with all of that,” she said.

I don’t know how this can be translated to our culture. I can only imagine that if each of us worked at processing our own feelings, we might start a trend of separating physical appearance from all of the other markers of health and happiness. Can you imagine the impact that might have on the advertising industry?

As always, I’d like to know what you think!

* Names and identifying information changed to protect privacy

To read more on Body Dysmorphic Disorder:

Fang A, Matheny NL, Wilhelm S. (2014) Body dysmorphic disorder

Bjornsson AS, Didie ER, Phillips KA. (2010) Body dysmorphic disorder.

DSM-5: Body Dysmorphic Disorder Or Obsessed With Appearances? By Wayne Perry

Why Do Women Hate Their Bodies? By Carolyn Coker Ross, MD

To read more about how and why we use food, diet and exercise to deal with feelings:

F. Diane Barth, LCSW 2014 Putting it all together: An integrative approach to psychotherapy with eating disorders. Psychoanalytic Social Work, 21, pp.19-39

F. Diane Barth, LCSW 2008 “Hidden Eating Disorders: Attachment and Affect Regulation” in Clinical Social Work Journal vol 36, pp.355–365

Jean Petrucelli 2014 Body-States:Interpersonal and Relational Perspectives on the Treatment of Eating Disorders (Routledge Publishers)

Kathryn J. Zerbe 2014 Integrated Treatment of Eating Disorders: Beyond the Body Betrayed (Norton Publishers)