Eating disorders can plague both males and females, and they generally have different unattainable physical appearance-related goals. Males may feel the need to develop large muscles and are more vulnerable to taking drugs or embarking on exercise regimens that move them in that direction. For males who are obese or disinterested in athletics, there may be considerable social pressure and harassment to increase their muscle mass or overall strength. Females tend to gain weight and body fat during puberty. This tendency is in direct opposition to the “skinny” images they are exposed to through the media. As a consequence, girls are more likely to diet and exercise in ways that emphasize thinness and weight loss instead of fitness. These actions can result in eating disorders. Anorexia nervosa, the act of starving oneself, and bulimia nervosa, the act of binging and purging, are chronic conditions among many children and adolescents.
For this Assignment, consider the differences between normal variations in body image and what constitutes an eating disorder. In addition, consider what types of interventions are most effective with children and adolescents with eating disorders.
The Assignment (2–3 pages):
Body Image 1 (2004) 15–28
Body image in children and adolescents:
where do we go from here?
Linda Smolak∗
Department of Psychology, Kenyon College, Gambier, OH 43022, USA
Received 15 June 2003; received in revised form 17 July 2003; accepted 17 July 2003
Abstract
During the past two decades, there has been an explosion of research concerning body image in children and adolescence.
This research has been fueled both by concern about the effects of poor body image in children and adolescents themselves and
by the assumption that body dissatisfaction during childhood and adolescence creates risk for the development of body image
and eating disturbances as well as depression in adulthood. The extant research, however, has remained largely descriptive and is
marked by methodological problems. The purpose of the present paper is to identify substantial gaps in the literature concerning
body image in children and adolescents. The focus is on four major issues: (1) measurement, (2) epidemiological data, (3)
developmental trends, and (4) the meaning of gender. Addressing these and related questions will aid in the development of
treatment and prevention programs.
© 2003 Elsevier B.V. All rights reserved.
Keywords:Childhood; Measurement; Development; Gender
Introduction
It is invariably instructive to interview children
about their appearance. There are the children, most
typically average size girls, who lower their eyes,
heads, and voices as they answer the questions on the
Body Esteem Scale (BES;Mendelson & White, 1993)
and tell us that no, they do not like the way they look
in pictures, yes, they wish they were thinner, and no,
their classmates do not want to look like them—why
would anyone want to look like them? There are the
young children who are already modifying what they
eat or doing aerobics with their moms in order to
∗ Tel.: +1-740-427-5374; fax:+1-740-427-5237.
E-mail address:smolak@kenyon.edu (L. Smolak).
lose weight. They surprise us with their knowledge of
weight loss and body sculpting techniques, specify-
ing commercial diet programs, such as Jenny Craig,
by name. Even more stunning was the first grader
who told us you would need to throw up after eat-
ing or the elementary schoolers who thought plastic
surgery would be necessary to achieve the body ideal
portrayed by Christina Aquilera or Britney Spears
(Murnen, Smolak, Mills, & Good, in press).
These experiences point to one of the reasons re-
searchers, educators, and parents are concerned about
body image in children. It is clear that some children
are already worried about their ability to look “good
enough” to be accepted by others. They are saddened
and embarrassed by their looks. They are already try-
ing food restriction and exercise techniques to change
1740-1445/$ – see front matter © 2003 Elsevier B.V. All rights reserved.
doi:10.1016/S1740-1445(03)00008-1
16 L. Smolak / Body Image 1 (2004) 15–28
their bodies. Some of these attempts may be health
endangering. Thus, there seem to be children whose
lives are already being negatively affected by poor
body image.
These anecdotes also raise the possibility that the
foundation of body dissatisfaction is laid in childhood.
There is prospective, longitudinal evidence that ado-
lescent body dissatisfaction and especially concerns
about being or becoming fat is related to the develop-
ment of eating problems, eating disorders, and depres-
sion (e.g.,Leon, Fulkerson, Perry, & Early-Zald, 1995;
McKnight Investigators, 2003; Stice, 2002; Stice &
Bearman, 2001; Stice, Hayward, Cameron, Killen, &
Taylor, 2000; Wichstrom, 1999). Finding the roots of
this risk factor will be crucial in both the prevention
and treatment of eating disorders and depression.
But experiences and anecdotes are not data. There
is now a sizeable body of studies of body image in
children and adolescents (for reviews, seeRicciardelli
& McCabe, 2001a; Smolak & Levine, 2001), but there
are even more unanswered questions. The purpose of
this paper is to raise four broad questions, each with
several accompanying specific issues that need to be
addressed empirically. These issues focus on (1) mea-
surement, (2) epidemiological data, (3) developmental
trends, and (4) the meaning of gender. Research on
these, and related, questions will expand our knowl-
edge base about body image in children which will,
in turn, provide an empirical foundation for preven-
tion and treatment programs for body image and eat-
ing problems.
How should we define and measure body image
in children?
Researchers have long argued that body image
is multidimensional with at least perceptual, affec-
tive, cognitive, evaluative, and investment/behavioral
components (e.g.,Muth & Cash, 1997; Thompson,
Heinberg, Altabe, & Tantleff-Dunn, 1999). These dis-
tinctions have been supported empirically in adoles-
cents and adults (e.g.,Muth & Cash, 1997; Thompson,
Altabe, Johnson, & Stormer, 1994). These distinctions
have rarely been addressed in research with children,
though they occasionally surface in research with ado-
lescents (e.g.,Ricciardelli & McCabe, 2003). Indeed,
several of the measures of body esteem commonly
used with children, such as the BES, cover a broadly
defined construct and do not allow the researcher to
specify the body esteem problem.
In addition, current research does not generally
have a way to identify problematic levels of body
dissatisfaction. AsCash (2002a)has argued with
respect to defining “negative body image,” dissatis-
faction alone is an insufficient criterion; the emotional
and behavioral consequences of such dissatisfaction
must the considered. If body dissatisfaction is in
fact a “normative discontent” (Rodin, Silberstein, &
Striegel-Moore, 1985) among girls and women, it is
important to distinguish the girl who is engaging in
socially sanctioned “fat talk” for the sake of seeming
friendly from the child who is on a path to eating
disorders or depression. While a few studies have
identified “cut-offs” for weight concerns among ado-
lescents for identifying girls at risk for developing eat-
ing problems (e.g.,Killen et al., 1996), such research
is not available for children. Nor have similar cut-offs
been established for ethnic minority girls or for
boys.
Evaluative body image
Body image evaluation, which refers to how sat-
isfied one is with one’s body (Muth & Cash, 1997),
is probably the most common aspect of body image
that is measured in children. This is also sometimes
referred to as attitudinal body image (Gardner, 2002).
Both figure drawings and questionnaires have been
used to assess body dissatisfaction in children and ado-
lescents.
Being able to evaluate one’s body requires that the
child can assess her/his own body, has an ideal to
which to compare her/his body, and is capable of mak-
ing such a comparison. It is possible that one must be
more than aware of the ideal; perhaps the ideal needs
to be internalized (Thompson & Stice, 2001) before
meaningful body dissatisfaction will develop. Clearly,
these components are in place by adolescence. But
when do they first appear?
In terms awareness of the culturally defined ideal
body, there are data indicating that 5 year olds
have absorbed the cultural bias against fat peo-
ple (Cramer & Steinwert, 1998; Musher-Eizenman,
Holub, Edwards-Leeper, Persson, & Goldstein, 2003).
Three year olds may also be aware of the anti-fat
L. Smolak / Body Image 1 (2004) 15–28 17
prejudice but they are less committed to it. They
are less likely to ascribe negative characteristics to
fat children than 5 year olds are (Musher-Eizenman
et al., 2003). However, the 5 year olds have a wider
range of what constitutes an acceptable body type
than do adults (Musher-Eizenman et al., 2003).
Unfortunately, these studies are marked by method-
ological problems. The samples tend to be small
as well as white and middle-class, the designs are
cross-sectional, and there are questions about the
measures. For example, it is not clear that preschool
and even early elementary school children can use
checklists of fairly abstract personality characteris-
tics (Musher-Eizenman et al., 2003). Indeed, they do
not use these types of terms to describe other people
(Ewell, Smith, Karmel, & Hart, 1996). Researchers
have not looked at whether measures such as the
Sociocultural Attitudes towards Appearance Ques-
tionnaire (SATAQ;Heinberg, Thompson, & Stormer,
1995) that measure awareness and internalization of
the thin-ideal are valid with preschool and early ele-
mentary school children, although revised forms do
appear to have validity with adolescents (Smolak,
Levine, & Thompson, 2001). Musher-Eizenman et al.
(2003) developed a story-based measure of fat prej-
udice. However, they do not provide psychometric
data, such as test–retest or internal consistency for
the measure. There are, then, questions as to how
to measure body ideal and fat prejudice in young
children.
There are also questions as to how children report
their “current” body types. Ideally, construct validity
of a measure would be assessed by correlating the
child’s actual BMI with the selected “current” figure
(in figural measures) or the chosen body shape cat-
egory (in questionnaires). Unfortunately, BMI stan-
dards vary by age and gender. Therefore, it is not clear
that BMI in preschoolers carries the same meaning that
it does in adults. Researchers have used BMI, BMI per-
centile (based, for example, on the Centers for Disease
Control data), and ponderal index (height/ 3
√
weight)
to assess levels of weight for height among children.
Without a valid criterion, it will be difficult to estab-
lish the construct validity of the child’s own body rat-
ings. Research must examine the relationships of BMI,
BMI percentiles, and ponderal index in young chil-
dren to future weight, body dissatisfaction, and eating
problems.
Figure drawings
Despite the problems with establishing the validity
of the current and ideal body shape components, there
are several versions of figure drawings that have been
used in research with children and adolescents. For
many of these, few or no psychometric data are avail-
able (seeGardner, 2001, 2002, for reviews). Proba-
bly the most commonly used of child figure drawings
measure was developed byCollins (1991). In her arti-
cle, Collins (1991)reports an overall 3-day test–retest
coefficient for current self of first to third graders of
0.71. She does not report this correlation by grade
though she notes that figure selections “were stable in
many instances. . . but dropped sporadically in others”
(Collins, 1991, p. 203) when the analyses were per-
formed by grade and gender. The test–retest correla-
tions for other figure selections, including ideal self,
ideal other child, and ideal adult, did not reach the
acceptable level of 0.70 despite an interval of only
3 days. Furthermore, criterion validity correlations,
though statistically significant, were not impressive.
The correlation between pictorial self-selection and
weight was 0.36 while the correlation between BMI
and self rating was 0.37.
There are even fewer data available for preschool
age children. Not surprisingly, the news is worse.
Using an adaptation ofCollins’s (1991) figures,
Musher-Eizenman et al. (2003)found no correlation
between preschool children’s height or weight and
their “current” body size rating. They did find a sub-
stantial correlation of 0.84 between the children’s
mothers’ ratings of maternal current body size and ma-
ternal BMI. Thus, while heavier adult women actually
select drawings depicting heavier people, children’s
selections are unrelated to their actual body size.
Quite simply, we do not have the validity data
to reliably use figure drawings with young children
(approximately≤8 years old). In fact, the data have
not been collected to clearly indicate at what age the
current and ideal ratings, and hence the body dissat-
isfaction measures they constitute, become reliable,
although questionnaire data indicate that adolescents’
ratings should be reliable.
Questionnaires
Many researchers have simply asked adolescents a
single question such as “How satisfied are you with
18 L. Smolak / Body Image 1 (2004) 15–28
your appearance?” The only construct validity we have
for such questions is that they often show the expected
correlations with weight control strategies or eating
problems. Typically, test–retest is not reported.
One of the best available scales for assessing body
dissatisfaction among older children and adolescents
is the Eating Disorders Inventory Body Dissatisfaction
scale (EDI-BD;Garner, Olmstead, & Polivy, 1983).
Adequate internal consistency has been reported with
girls as young as 8 and for both boys and girls aged
11–18 years (Shore & Porter, 1990; Wood, Becker, &
Thompson, 1996). It also does seem to focus on the
evaluation component of body image. However, be-
cause this scale was developed to focus specifically
on body areas of greatest concern to females with eat-
ing disorders, its content narrowly emphasizes feelings
about one’s hips, thighs, buttocks, and stomach.
Several other measures, especially the BES
(Mendelson & White, 1993) and weight concerns
(Killen, 1996; Shisslak et al., 1999) have also shown
good internal consistency and reasonable test–retest
reliability. In the case of weight concerns, these forms
of validity have been demonstrated in children as
young as fourth grade (Shisslak et al., 1999). Further-
more, weight concerns has been shown to predict the
development of eating disorders, at least among ado-
lescents (Killen et al., 1996; McKnight Investigators,
2003). Unfortunately, weight concerns mixes evalua-
tive and investment aspects of body image and so can
be difficult to interpret. Furthermore, one attempt to
use it with 5–9 year olds indicated poor internal con-
sistency (α < 0.70; Davison, Markey, & Birch, 2003).
Affective body image
There are several self-esteem scales that tap feelings
about body or appearance in children and adolescents.
These are only occasionally used by body image re-
searchers. However, some of them do demonstrate
at least internal consistency and test–retest reliabil-
ity and so should be considered more thoroughly by
body image researchers. They might even serve as
criterion variables for researchers trying to develop
“purer” measures of body image focusing on mus-
cles or weight. These scales include the Self-Image
Questionnaire for Young Adolescents (Petersen,
Schulenberg, Abramowitz, & Offer, 1984), the Offer
Self Image Questionnaire (Offer, Ostruv, & Howard,
1984), and the Harter Scales (Harter, 1985). Harter’s
Scales are applicable to both children and adolescents
and so may be particularly useful in longitudinal
research.
Body image investment
Body image investment involves both cogni-
tive and behavioral indicators of the importance of
one’s appearance to one’s sense of self. Several re-
searchers have offered lists of weight control tech-
niques or muscle-building techniques to boys and
girls (e.g.,Levine, Smolak, & Hayden, 1994; Shisslak
et al., 1999; Smolak et al., 2001). Perhaps one of
the better-developed measures isRicciardelli and
McCabe’s (2002)Body Change Inventory. This scale
consists of three subscales: strategies to decrease body
size, strategies to increase body size, and strategies
to increase muscle size. As such, it is applicable to
both boys’ and girls’ body concerns since boys may
be as interested in gaining as in losing size (Smolak
& Levine, 2001). There is also some evidence that
African American girls may be interested in gaining
size (Thompson, Corwin, & Sargent, 1997), so this
scale may be of interest to researchers investigating
ethnic differences in body image.Ricciardelli and
McCabe (2002)report extensive exploratory and con-
firmatory factor analyses in the development of these
scales as well as concurrent and discriminant validity.
The scale was developed for use with adolescents,
with 11 year olds being the youngest children in their
samples.
Body image schema
Several authors have suggested that a body image
schema guides the interpretation of sociocultural in-
fluences, such as media images (Cash, 2002b; Markus,
Hamill, & Sentis, 1987; Smolak & Levine, 1994, 1996,
2001; Smolak, Levine, & Schermer, 1998; Vitousek &
Hollon, 1990). The schema serves as a mediator be-
tween the sociocultural influences and poor body im-
age. The schema is thus crucial in understanding why
some people are so negatively affected by sociocul-
tural influences while others are not.
Smolak and Levine (1994, 2001)have further ar-
gued that such a schema, which they term a “thinness
schema,” develops during childhood and is in place,
L. Smolak / Body Image 1 (2004) 15–28 19
at least in an immature form, by early adolescence.
They suggest, then, that young children will be rel-
atively less resistant to the messages in universal
prevention programs. These children will not yet have
integrated beliefs about appearance—including cul-
tural ideals, the importance of meeting such ideals,
and the means to attain such an appearance—with
each other into a cognitive schema. Furthermore, the
children will not have fully integrated such ideas into
their self-systems. It is for this reason that Smolak and
Levine have argued strongly for universal prevention
programs aimed at elementary school age children.
The ability to measure the development of body im-
age schemas has theoretical and applied importance.
Cash, Melnyk, and Hrabosky (in press)have devel-
oped a measure to assess body image schemas among
adults. The Appearance Schemas Inventory-Revised
(ASI) has two factors. One factor measures the
self-evaluative salience of one’s appearance (e.g.,
“What I look like is an important part of who I am.”
“When I meet people for the first time, I wonder
what they think about how I look.”), while the other
factor assesses the simpler motivational salience of
appearance (e.g., “Before going out, I make sure
that I look as good as I possibly can”) (Cash et al.,
in press). Cash and his colleagues have presented
substantial psychometric information concerning this
scale using a college-age sample.
No comparable measure is available for children
or even young adolescents. Given the argument that
the thinness schema is gradually constructed during
childhood (Smolak & Levine, 1994, 1996, 2001), it
will be crucial to develop and validate a measure that
might tap into the developmental process.
Summary
There are tools for measuring body image in chil-
dren. As one might expect, they are not as extensively
developed as those available for adults and even for
adolescents. What is surprising is how very lim-
ited our assessment arsenal is. We are especially ill
equipped to measure body image in children who
are under 10 (third grade or younger in the United
States). It is absolutely imperative that new measures
be developed and that both new and existing measures
be more rigorously subjected to psychometric evalua-
tion. Such work is time consuming and can even seem
tedious at times. It is often difficult to get schools to
agree to participate in research whose primary aim is
assessment development. Yet, the questions raised in
the remainder of this chapter—and indeed all ques-
tions concerning body image in children—cannot be
answered without such research.
How are body image problems distributed?
In reading the popular press, it is not unusual to
see figures suggesting that as many as 60% of ele-
mentary school girls are dissatisfied with their bodies.
Such numbers are usually based on a single study. In
reviewing several studies,Smolak et al. (1998)con-
cluded that it was fairly common to find that about
40% of late elementary school (typically fourth and
fifth grade) girls reported body dissatisfaction.
Even this is a misleading number, however. First,
the studies have fairly small samples, at least in terms
of epidemiology. Second, the samples are overwhelm-
ingly white. It is not clear that girls from ethnic mi-
nority groups, particularly black girls, share the same
body image concerns as white girls do. Third, there are
several different measures used in the studies, some of
which focused on body in general, others on weight
and shape per se.
These concerns do not even address several im-
portant limitations. First, boys are not well repre-
sented. While research is now appearing that looks at
boys’ body image (e.g.,Corson & Andersen, 2002;
Ricciardelli & McCabe, 2003; Smolak et al., 2001),
there are no epidemiological data available. Second,
ethnic groups’ differences are poorly understood.
Third, we have few data on children under 10.
Such limitations make it difficult to establish when
body dissatisfaction becomes a problem. For exam-
ple, when are ideal-current figure rating differences
large enough to indicate a body image problem may
exist? Without large-scale standardization studies and
epidemiological data, it is difficult to know what is an
unusual or pathological level of body dissatisfaction.
What are the developmental trends in
body image development?
Similarly, we know little about the development
of body image, particularly during the preschool and
20 L. Smolak / Body Image 1 (2004) 15–28
early elementary school years.Davison et al. (2003)
reported an improvement in body esteem during
the early elementary school years (ages 5–9 years).
During middle school, both boys and girls seem to
experience a decrease in body esteem although boys’
decrease may be less dramatic and may show a faster
recovery than girls’ decrease does (e.g.Abramowitz,
Peterson, & Schulenberg, 1984; Rosenblum & Lewis,
1999; Wichstrom, 1999).
It is not yet clear at what point body image becomes
reasonably stable.Davison et al. (2003)reported
significant, but small to moderate (r = 0.23–0.37)
correlations between body esteem at ages 5, 7, and 9,
Smolak and Levine (2001)reported no significant re-
lationships between body esteem measured in grades
1–3 and again 2 years later.Smolak and Levine
(2001) also reported that body esteem measured in
fourth or fifth grade was related to body esteem mea-
sured 2 years later.Cattarin and Thompson (1994)
similarly found that body dissatisfaction was quite
stable in a group of 10–15-year-old girls followed
over a 3-year period. Both theDavison et al. (2003)
and theSmolak and Levine (2001)studies had rela-
tively small samples of white girls, leaving us a long
way from establishing when stability of body image
occurs.
Developmental trends must be mapped for the var-
ious components of body image. It is not necessarily
the case that evaluation, affect, and investment develop
in tandem. Indeed, it seems likely that evaluation pre-
dates investment. Some studies have found, for exam-
ple, substantially fewer elementary school aged girls
engaging in dieting than reporting body dissatisfaction
(e.g.Smolak et al., 1998). This finding is underscored
by the considerably lower correlations between body
dissatisfaction and measures of dieting in elementary
school girls when compared to those of adults (Smolak
& Levine, 2001). The value of either the individual
components or their interrelationships to predict de-
pression or eating problems or even later body image
problems is also an important developmental issue.
Risk factors and protective factors for the devel-
opment of body image problems may also change.
Several risk factors (seeStice, 2001, 2002, for re-
views) that appear to foster body image problems in
adolescence and adulthood also may be operative in
childhood. For example, media influences and parental
comments appear to affect body image by late ele-
mentary school (e.g.,Field et al., 1999; Smolak et al.,
1998; Taylor et al., 1998). Sexual harassment is re-
lated to poorer body esteem, at least among girls, in
elementary school (Murnen & Smolak, 2000). Many
of these studies are cross-sectional and most involve
only white girls. There is much work to be done on
risk factors for body image problems, particularly dur-
ing the preschool and early elementary school years.
BMI may be a particularly interesting example
of a risk factor whose meaning may change across
childhood. BMI is correlated with body dissatisfac-
tion in both adolescent and adult men and women.
Body dissatisfaction may show a curvilinear relation-
ship for men and a linear relationship for women and
concerns about being fat may be more clearly tied
to being overweight for men than for women (e.g.,
Dornbusch et al., 1984; McCreary, 2002; Muth &
Cash, 1997). In the preschool years, children’s body
size is not related to their appraisal of their current
body type (Musher-Eizenman et al., 2003). Davison
et al. (2003)reported small but significant correla-
tions between BMI and body dissatisfaction in 5–9
year olds. The size of the correlations increased with
age (r = 0.13–0.27). Davison, Markey, and Birch
(2000) reported a correlation of 0.17 between BMI
and body dissatisfaction for 5-year-old girls while
the comparable correlation for the girls’ mothers was
0.77 and for their fathers was 0.61. Weight concerns
were not associated with weight status among the
5 year olds.
The lesser strength of the relationships between
BMI and body esteem in younger children is con-
sistent with the argument that fat prejudice increases
with age (Cramer & Steinwert, 1998; Wardle, Volz, &
Golding, 1995). It is also consistent with Levine and
Smolak’s argument (Levine et al., 1994; Smolak &
Levine, 2001) that the “thinness schema,” a cognitive
structure integrating thin-ideal, body dissatisfaction,
and weight control techniques, may be less consoli-
dated in younger children than in adolescents. If this
is so, then elementary school may be a particularly
appropriate time for universal programs aimed at pre-
venting body image and eating problems. Thus, the
BMI-body dissatisfaction relationship demonstrates
the importance of charting changing patterns in the
development of body image.
Even among adults, there is little research concern-
ing factors that might protect against the development
L. Smolak / Body Image 1 (2004) 15–28 21
of body image and eating problems (Crago, Shisslak,
& Ruble, 2001). Murnen et al. (in press)reported that
elementary school girls who actively reject the sexu-
alized thin-ideal media image of women have higher
body esteem.Smolak, Murnen, and Ruble (2000)
found that high school girls participating in non-elite
sports had better body esteem whileGeller, Zaitsoff,
and Srikameswaran (2002)reported that basing com-
petence on academic and other activities (including
sports), rather than on appearance, was associated with
more positive body esteem in high school girls. In 5-
and 7-year-old girls, participation in aesthetic sports
(e.g., dance or gymnastics) has been correlated with
higher weight concerns, a relationship that echoes that
found with adults (Davison, Earnest, & Birch, 2002).
However, participation in non-aesthetic sports (e.g.,
basketball or soccer) did not emerge as a protective
factor. This may be another example of a changing re-
lationship between a risk or protective factor and body
image. It is possible that non-aesthetic sports partic-
ipation means something different to younger girls
than to adolescents. Currently, we do not have enough
data to definitively document developmental changes
in this relationship much less the basis for those
changes.
While first graders are capable of social com-
parison, older children engage in the process much
more frequently (Smolak, 1999). Social comparison
may well be an important mediator in the develop-
ment of body esteem (e.g.Stormer & Thompson,
1996). Similarly, self-esteem becomes more differ-
entiated with age (Harter, 1986). Self-esteem is also
more likely to suffer as social comparison becomes
a more powerful source. Thus, the mediating roles
of social comparison and self-esteem, as well as the
relationship between them, may change as children
develop.
Developmental considerations have not yet been
adequately addressed in the body image literature.
Indeed, in some areas we have virtually no data
concerning the developmental changes in risk or pro-
tective factors. There are even relatively few data
available on the nature of changes in body image it-
self, particularly if one wishes to examine either the
components of body image or the differences in body
image development by ethnicity, gender, or culture.
Such information will be critical to the development
of effective prevention and treatment programs.
What is the role of gender in body image
development?
Body image is a strongly gendered phenomenon.
In the past, a statement like this has often been inter-
preted as meaning that boys and men do not have body
image problems. This is clearly not true. Nonetheless,
it is evident that the nature, risk factors, outcomes, and
probably the developmental course of body dissatis-
faction differ by gender. While it is important to iden-
tify gender differences in patterns in the development
of body image, it is probably more crucial to work
toward understanding why gender differences exist at
all.
Patterns
Until recently, virtually all research on body dissat-
isfaction in children and adolescents focused on con-
cerns about being too fat and methods to prevent or
reduce body fat. The findings concerning dissatisfac-
tion about being fat are quite clear. Girls are more
worried about fat than boys are (seeSmolak & Levine,
2001 for a review). This gender difference is evident
in elementary school and in every American ethnic
group that has been studied. It is related to the onset of
gender differences in depression in early adolescence
(Wichstrom, 1999). It is likely that it is one of the con-
tributing factors to the gender differences in the eating
disorders, anorexia nervosa (AN) and bulimia nervosa
(BN). This is a critically important gender difference,
then, since it is related to the development of a vari-
ety of pathological, and, in the case of AN, potentially
fatal, outcomes.
One of the reasons girls are more dissatisfied in
terms of body fat is they are more likely to judge
themselves as fat when they are average-weight, and
even under-weight (e.g.,Dornbusch et al., 1984;
McCreary, 2002). Boys and men are most likely to
be concerned about being fat when they actually
have high BMIs. This may reflect the greater societal
emphasis on the appearance of women’s rather than
men’s bodies (Fredrickson & Roberts, 1997).
On the other hand, boys are more likely than girls to
want to increase the size of their muscles (seeCorson
& Andersen, 2002; McCabe & Ricciardelli, in press,
for reviews). By sometime in adolescence, the de-
sire for larger muscles becomes about equivalent to
22 L. Smolak / Body Image 1 (2004) 15–28
or greater than the interest in losing weight among
boys (e.g.,Furnham & Calman, 1998; Ricciardelli &
McCabe, 2001b,c). If the boys who are dissatisfied
with their bodies because they are too fat are combined
with those who are unhappy because their muscles
are too small, then the frequency of body dissatis-
faction is similar among adolescent boys and girls
(McCabe & Ricciardelli, in press). It is important to
note, however, that this isnot true of children younger
than about age 11 years. Young boys are apparently
not very concerned about building muscles, although
the research is very sparse (e.g.,Polce-Lynch, Myers,
Kilmartin, Forssmann-Falck, & Kliewer, 1998). This
may reflect an important gender difference in the so-
ciocultural demands concerning bodies. While prepu-
bertal boys are not expected to meet the adult male
muscular body ideal, young girls are expected to try
to achieve the adult female thin body ideal. Hence, the
pressure on girls to achieve a certain body type may be-
gin earlier than the comparable pressure on boys. This,
in turn, might mean that issues of body image are more
fully incorporated in the self-systems of girls than of
boys. This is an important issue for future research.
Boys’ concerns about muscularity also carry
risk. By middle school, there is an association be-
tween concerns about muscularity and the use of
muscle-building techniques (Ricciardelli & McCabe,
2003; Smolak et al., 2001). Anabolic steroid and food
supplement abuse are among the techniques that boys
use to gain muscle. Boys are more likely to use these
techniques than girls are. Furthermore, steroid abuse
may be at least as common among adolescent boys as
AN is among adolescent girls (McCabe & Ricciardelli,
in press). The effects of steroid use in older boys and
men are well established (National Institutes of Drug
Abuse, 2000); indeed, anabolic steroid abuse may
even be fatal. These effects may be exacerbated dur-
ing the developmental period. This may also be true
of food supplements, such as ephedra, whose effects
are generally poorly understood. There is a desper-
ate need for research that more intensely examines
the link between body image and steroid and food
supplement abuse in boys.
At the extreme end, behavioral outcomes of body
dissatisfaction may be comparably dangerous for boys
and for girls. At more moderate levels, however, body
image may be more problematic for girls. Some evi-
dence suggests that girls are more likely to act on their
body dissatisfaction (e.g.,Hill, Draper, & Stack, 1994;
Kelly, Ricciardelli, & Clarke, 1999; Smolak & Levine,
1994; Smolak et al., 2001). This might be interpreted
as indicating that boys have lower body image in-
vestment, a finding consistent with the adult literature
(Cash et al., in press; Muth & Cash, 1997). It is es-
pecially the case that girls are more likely to engage
in calorie restrictive dieting than boys are (Smolak
& Levine, 2001). Dieting has short-term effects, in-
cluding fatigue, headaches, and irritability. It also has
long-term health-endangering effects, including eating
problems, obesity, growth stunting, and bone density
loss (e.g.,Davis, Apley, Fill, & Grimaldi, 1978; Stice,
Cameron, Killen, Hayward, & Taylor, 1999). These
important problems may well be intensified when di-
eting occurs during childhood and adolescence.
Girls’ greater investment in body image may be
rooted in different cultural definitions of the female
versus the male body (Bordo, 1993; Fredrickson &
Roberts, 1997). While the male body is viewed as
agentic and active, the female body is an object to
be looked at, particularly by men. The function of
women’s bodies, then, is to be attractive, to be sexually
pleasing to men. Girls learn this lesson early with mes-
sages coming from media, peers, and parents (Smolak
& Murnen, 2001, in press). Messages to girls may be
more consistent, both in terms of number of sources
and the clarity of the message, than those directed at
boys. This may suggest etiological differences in body
image problems for girls and for boys.
Etiology
It is important that researchers increasingly focus
on the process of the gendered development of body
image. There are at least two broad questions concern-
ing gender differences in the etiology of body image.
First, there is the issue of whether boys and girls have
different experiences in terms of their bodies. Second,
we must address whether these experiences have the
same meaning for boys and girls.
Experiences
body image researchers have emphasized socio-
cultural factors, particularly peer, parent, and media
influences, as possible contributors to the develop-
ment of body dissatisfaction. While there are some
L. Smolak / Body Image 1 (2004) 15–28 23
similarities in boys’ and girls’ exposure to negative
influences, there are also some potentially important
differences. Not surprisingly, there is more evidence
available for girls than for boys, and there is more
research concerning wanting to be thinner than want-
ing to be more muscular. Therefore, even at the basic
level of describing gender differences in exposure to
body-related influences, substantially more research is
needed.
Parents generally like the way their young children
look, though they become more dissatisfied as the
children get older (Striegel-Moore & Kearney-Cooke,
1994). Parents also do not appear to direct more com-
ments about the child’s body to their daughters than
to their sons (Smolak, Levine, & Schermer, 1999;
Striegel-Moore & Kearney-Cooke, 1994). By adoles-
cence, girls may be more likely to actually discuss
weight loss with their mothers than boys are although
there is still no gender difference in direct parental
encouragement for the child to lose weight (Vincent
& McCabe, 2000). High school girls also report more
maternal modeling of weight loss behavior than boys
do (Vincent & McCabe, 2000).
Peer influences also vary by gender. Appearance-
related teasing is the most common form of teasing
among children. Boys are more likely to engage in
teasing than girls are. Accordingly, adolescent boys re-
port more negative comments about their bodies from
their peers than girls do (Vincent & McCabe, 2000).
However, girls are more likely than boys to discuss
weight and weight loss than boys are (Oliver & Thelen,
1996; Vincent & McCabe, 2000). Indeed, girls may
routinely engage in “fat talk,” disparaging their nor-
mal weight bodies for the purpose of fitting in socially
(Nichter, 2000).
Media is a multi-faceted influence on body image
(see Levine and Harrison, in press, for a review). Dif-
ferent television shows portray body image differently
with soap operas showing a more rigidly thin-ideal
for girls than, for example, dramas do. Girls are more
likely to watch soap operas than boys are. Further-
more, the acceptable body type portrayed for women
is narrower than that for men on television and fat
women are the single group most likely to be the tar-
get of jokes. In addition, many more girls’ magazines
focus on appearance than do boys’ magazines (Levine
& Smolak, 1996). Girls begin reading these magazines
on a fairly regular basis in late elementary school.
For example,Field et al. (1999)found that roughly
25% of late elementary school girls read “fashion”
magazines at least twice a week, a number that rises
at least through middle school (Levine et al., 1994).
Little is known about boys’ use of magazines, other
than thatSports Illustrated, a magazine that portrays
active, although sometimes unrealistically muscular,
male bodies, is the one most commonly read. Thus,
this may be another indicator of the greater sociocul-
tural pressure on young girls to achieve a particular
body type.
There are data suggesting that some girls are more
susceptible than others to at least peer and media
influences (e.g.,Levine et al., 1994; Taylor et al.,
1998). Such research is not available yet for boys. Re-
searchers looking at self-esteem and body comparison
as mediators, for example, have generally treated eat-
ing disorders or weight loss or muscle-building tech-
niques as the dependent variable with body dissatis-
faction serving as a predictor variable. Much more re-
search is needed on how children of both genders as-
similate media, peer, and parental messages into their
own body images.
Meaning
There is evidence that the interpretation of cultural
messages varies by gender. Given the extent of be-
havioral and attitudinal gender differences and gender
roles, this does not seem surprising. Yet, few studies
have examined such differences and their implications
for body image development.
Murnen and Smolak (2000)interviewed third
through fifth grade boys and girls about gendered
harassment, behaviors that might be considered early
forms of sexual harassment. Boys and girls reported
equal frequencies of being harassed. However, girls
were more likely than boys to report that victims
would be frightened by the harassment. This is con-
sistent with findings with adolescents suggesting that
girls are more likely than boys to change their be-
havior to avoid harassment (American Association
of University Women, 2001). Murnen and Smolak
(2000) found that girls who were thought victims
would be afraid had lower body esteem than other
girls. Girls who said they did not know how the vic-
tims would react were more likely than other girls to
report lower body esteem. This was not true for boys.
24 L. Smolak / Body Image 1 (2004) 15–28
In fact, overall, frequency of sexual harassment was
negatively correlated with body esteem for girls but
not for boys.
Girls seem to be more directly and extensively af-
fected by media images than boys are (Ricciardelli &
McCabe, 2003; Smolak et al., 2001). Is this because
of characteristics of the media, such as the greater
consistency of the thin-ideal for women than for the
muscular ideal for men? Or is it because the mes-
sage to girls is more salient because it is reinforced
by various forms of media as well as by peers and
parents? Is it because girls are often socialized to be
more “cooperative” and to try to do more to maintain
relationships? These and other hypotheses, which are
applicable to a variety of potential risk factors, deserve
much more research attention.
Ethnicity and culture
There is considerable consensus that sociocultural
factors are keys in understanding the development of
body image. If this is so, then one important tech-
nique for uncovering contributing variables would be
to compare development across ethnic and cultural
groups. Not only might researchers compare factors
between groups, they might also investigate the nature
of intra-group processes.
Despite the likely fruitfulness of a multiethnic,
multicultural approach, the overwhelming research
base for studies of body image in children has been
white and American, British, or Australian. Many
of the issues concerning gender also apply to ethnic
and cultural groups. Indeed, examining cultural dif-
ferences in gender differences and gender differences
within cultures will help us to tease apart influen-
tial variables. Such information will be crucial to
the development of “ethnically sensitive” prevention
programs (Smolak, 1999).
Conclusions
There are a number of findings about body image
in children and adolescents that have been replicated
sufficiently to think of them as facts. Some children
are quite concerned about their body shape, concerned
enough to do something such as diet or exercise in
order to change it. In elementary school, these children
are more likely to be girls than boys. This is true in
every American ethnic group studied to date as well
as in Australian and English children. Black girls may
be somewhat less dissatisfied with their bodies than
other girls are. By adolescence, boys are increasingly
concerned with becoming more muscular.
These trends are problematic for a variety of rea-
sons. Girls who are concerned about being thin are
at risk for dieting which in turn puts them at risk
for eating disorders and obesity. Body dissatisfied
girls are also at risk for depression. Boys who are
invested in becoming more muscular may resort
to health-endangering techniques such as anabolic
steroid use. Dieting and excessive exercise may also
be used to alter one’s body shape. These techniques
have potential short and long-term effects ranging
from fatigue to gastrointestinal distress to joint or
bone injuries.
There is also some evidence as to what factors might
influence the development of poor body image. So-
ciocultural factors such as media, peers, and parents
seem to be instrumental. Anti-fat biases, which first
appear in the preschool years, are also important. In
general, we have more information on these factors,
as well as the outcomes and the developmental trends
of body image, for girls than for boys and for white
children than ethnic minority children.
There are many unanswered questions. Before these
can be thoroughly addressed, we need to develop
better measures of body image, especially in young
children. At the moment, it is difficult to argue that
researchers have even measured body dissatisfaction
in preschoolers. There are also severe limitations on
what type of body image we know how to measure.
Again, this is particularly true of young children.
While researchers have begun to develop more gen-
der sensitive measures of body image, there is still
little research demonstrating the appropriateness of
measures for use with various ethnic groups.
There is also little epidemiological data available.
It is not yet clear how common body dissatisfaction
is at various ages for different genders and ethnic
groups. Given this, it is difficult to assess what levels
of body dissatisfaction are unusual. Such research will
need to be combined with prospective data looking
at pathological outcomes in order to establish what
levels of body dissatisfaction are problematic. These
levels are likely to vary by age, gender, and ethnicity.
L. Smolak / Body Image 1 (2004) 15–28 25
This is also true of developmental trends in body
image. For example, how do the relationships be-
tween risk factors and poor (or excellent) body image
change across development? When does poor body
image become predictive of eating disorders or steroid
abuse? Are the relationships among BMI, dieting,
muscle-building techniques, and body image constant
across development?
Then there is the issue of gender. Body image, as
well as its risk factors and outcomes, is a gendered
phenomenon. Researchers need to investigate the na-
ture, causes, and outcomes of these gender differences.
Understanding why boys and girls differ may help us
to identify risk and protective factors at various stages
of development. This is probably also true of ethnic
group differences. If black girls are indeed more sat-
isfied with their bodies than white girls are, for ex-
ample, then explicating the roots of black girls’ body
satisfaction may help in the more effective design of
prevention programs.
Prevention and treatment programs will benefit from
our increased knowledge of body image development.
The challenges of such research are great, but the ben-
efits are greater.
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Introduction
How should we define and measure body image in children?
Evaluative body image
Figure drawings
Questionnaires
Affective body image
Body image investment
Body image schema
Summary
How are body image problems distributed?
What are the developmental trends in body image development?
What is the role of gender in body image development?
Patterns
Etiology
Experiences
Meaning
Ethnicity and culture
Conclusions
References
Available online at www.sciencedirect.com
Cognitive and Behavioral Practice 18 (2011) 5–15
www.elsevier.com/locate/cabp
Integrating Motivational Interviewing and Cognitive Behavioral Therapy in the
Treatment of Eating Disorders: Tailoring Interventions to
Patient Readiness for Change
Josie Geller, St. Paul’s Hospital, Vancouver, and University of British Columbia
Erin C. Dunn, St. Paul’s Hospital, Vancouver
1077
© 20
Publ
This paper focuses on the integration of Motivational Interviewing (MI) and cognitive behavioral therapy (CBT) in the treatment of
eating disorders. Although CBT is regarded as the treatment of choice in this population, it nevertheless has limitations: some patients fail
to engage, drop out from treatment prematurely, or simply do not improve. These are common problems in a population characterized by
high levels of ambivalence about change. MI strategies can assist clinicians in enhancing readiness for change, tailoring interventions to
patient readiness status, and maintaining a therapeutic alliance throughout all stages of treatment. Preliminary research examining the
efficacy of adaptations of MI in the treatment of individuals with eating disorders has been promising. This paper presents 4 patient
scenarios involving individuals with varying degrees of readiness and in the context of different treatment settings. For each patient
scenario, key issues are described and common roadblocks to developing or maintaining a therapeutic alliance are provided. Vignettes
illustrate conversations between the patient and therapist for each scenario, highlighting how MI techniques can be integrated into CBT
treatment and promote a working therapeutic relationship that enhances long-term treatment outcome.
MILLIONS of individuals every year are affected byeating disorders: anorexia nervosa (AN), bulimia
nervosa (BN), and binge eating disorder (BED). Lifetime
prevalence for AN is approximately 0.5% to 1% for
females and .1% to .3% for males; lifetime prevalence for
BN is approximately 1% to 3% for females and .5% to 2%
for males; and lifetime prevalence for BED is approxi-
mately 2% to 5%, with no marked gender difference
(Dingemans, Bruna, & van Furth, 2002; Hudson, Hiripi,
Pope, & Kessler, 2007; Striegel-Moore, 2000; Woodside et al.,
2001). An even larger number of individuals suffer from
what is currently categorized as Eating Disorder Not
Otherwise Specified (EDNOS), which is best described as
a residual category for eating disorders of clinical severity
that do not meet diagnostic criteria for AN or BN
(Fairburn, 2008).
Eating disorders are characterized by serious distur-
bances in eating, such as binge eating, fasting, and
purging (i.e., engaging in compensatory weight control
behaviors), as well as subjective distress and excessive
concern about body shape and weight. These behaviors
are associated with a number of physical and psycholog-
ical consequences. Physical consequences include amen-
-7229/10/5–15$1.00/0
10 Association for Behavioral and Cognitive Therapies.
ished by Elsevier Ltd. All rights reserved.
orrhea, diabetes, hypertension, damage to teeth enamel,
osteoporosis, disturbances in kidney functioning, gastro-
intestinal bleeding, malnutrition, bowel disease, infertil-
ity, stress fractures, obesity, and cardiac arrest (Kaye,
Bulik, Thornton, Barbarich, & Masters, 2004; Keel et al.,
2003; Mitchell & Crow, 2006; Striegel-Moore, Leslie,
Petrill, Garvin, & Rosenheck, 2000). The mortality rate
for individuals with AN is the highest of any psychiatric
disorder and is more than 12 times higher than the
mortality rate among young women in the general
population (Birmingham, Su, Hlynsky, Goldner, & Gao,
2005). Increased mortality in eating disorders is frequent-
ly the result of medical complications or suicide (Birming-
ham et al, 2005; Franko & Keel, 2006). Individuals with
AN and BN have higher rates of mood, anxiety, and
personality disorders, as well as substance abuse, com-
pared to non-eating-disordered individuals (Becker,
Grinspoon, Klibanski, & Herzog, 1999; Carlat, Camargo,
& Herzog, 1997; Hudson et al., 2007; Stice, 1999;
Woodside et al., 2001). Individuals who meet criteria for
BED have been found to have higher lifetime prevalence
rates of major depressive disorder, panic disorder,
borderline personality disorder, and avoidant personality
disorder compared to non-BED individuals (Dingemans
et al., 2002; Telch & Stice, 1998). The public health
burden caused by untreated eating disorders is reflected
in high medical costs and loss of productivity due to
6 Geller & Dunn
impaired functioning. In addition, eating disorders
produce significant negative psychological and social
consequences for those who suffer from them, as well as
for their family and friends.
Although a number of studies have provided impor-
tant information about treatment for eating disorders,
further research is needed to improve efficacy, cost-
effectiveness, and dissemination of treatment for these
disorders. Treatment is often costly (because it is
delivered by highly trained specialists), can last for many
months or years, and fails to produce complete remission
in about half of the cases.
Treatment of Eating Disorders
Cognitive behavioral therapy (CBT) is generally
regarded as the treatment of choice for eating disorders.
CBT assumes that symptoms are maintained by placing a
high value on attaining an idealized weight and slender
shape, accompanied by inaccurate beliefs in three core
domains: unrealistic expectations for body weight/shape,
belief that obtaining such a weight/shape is necessary for
feelings of self-worth, and inaccurate beliefs about food
and how to influence weight. Thus, efforts to control
shape/weight lead to strict dietary control and, subse-
quently, both physical and psychological deprivation. This
deprivation, in turn, can make some individuals suscep-
tible to loss of control over eating. Thus, the goal of CBT
for eating disorders is to establish healthy eating habits by
removing the tendency to both undereat and overeat, the
former thought to encourage the latter. Maladaptive
attitudes about body shape and weight are also addressed.
If applicable, attention is given to stopping engaging in
compensatory weight control methods and relapse
prevention skills are developed to help individuals resist
the impulse to binge and/or purge.
Numerous studies have been conducted investigating
the efficacy of CBT for BN and BED and many reviews
conclude that CBT is associated with significant improve-
ments in bulimic symptomatology when compared to
wait-list control, other psychotherapies, and pharmaco-
therapy (Fairburn, Cooper, & Shafran, 2003; Fairburn &
Harrison, 2003; National Institute for Clinical Excellence,
2004; Wilson, 1999; Wilson & Fairburn, 1998). Although
manual-based CBT is currently the treatment of choice
for the bulimic disorders, there is little empirical support
for the use of CBT for AN, or for those cases that fall
within the large and heterogenous EDNOS category
(Treasure & Schmidt, 2008; Waller et al., 2008). However,
the transdiagnostic theory of eating disorders, which
focuses on the common core pathology of patients
displaying a range of disordered eating behaviors, posits
that CBT addresses the processes that maintain any type
of eating disorder (Fairburn et al., 2003; Fairburn, 2008).
Preliminary data from Fairburn and colleagues offer some
support for this approach when treating patients who
meet diagnostic criteria for AN, or those who are classified
as EDNOS (Fairburn & Grave, 2008).
Treatment Dropout and Failure to Engage
Despite CBT being the most frequently used and well-
researched treatment approach for eating disorders, it
has limitations: many patients fail to engage in treat-
ment, drop out prematurely, or simply do not improve
with this approach. A number of controlled treatment
trials using CBT for bulimic pathology have reported
excellent short-term reductions in symptom frequency,
but a 5-year follow-up study showed lasting remission
from bulimic behaviors in only half of those treated
(Fairburn et al., 1995). In a review of treatment dropout
in the eating disorders, attrition rates from research
trials ranged from 5% to 40%, with a median of 20%,
and dropout rates from clinical treatment ranged from
15% to 65%, with a median of 30% (Mahon, 2000).
High patient dropout and low remission or recovery
rates are problems in many areas of mental health
services, but are particularly prevalent among individuals
with eating disorders (Mahon, 2000); many individuals
with eating disorders are ambivalent about change
(Vitousek, Watson, & Wilson, 1998), which can often
result in a lack of engagement with therapy and premature
termination.
Recent attention has been given to reasons for patient
dropout from eating disorders treatment. The majority
of existing studies have focused on patient characteristics
that predict dropout, such as demographics, comorbid
diagnoses, and severity or duration of eating disorder.
However, no consistent findings link patient character-
istics to treatment dropout. More recently, the focus has
shifted from patient characteristics to therapy factors that
predict treatment dropout. It has been suggested by a
number of authors that therapeutic alliance and the
interaction between eating disordered patients and
therapists can have a profound effect on treatment
(Geller, Williams, & Srikameswaran, 2001; Kaplan,
Olmstead, Carter, & Woodside, 2001; Treasure &
Schmidt, 1999; Treasure et al., 1999; Wilson, Vitousek,
& Loeb, 2000). However, there has been insufficient
empirical research on this topic in the eating disorders,
and the research that has been conducted has been
limited by a number of methodological problems (e.g.,
small sample size) and has yielded inconclusive results.
Nevertheless, it is well recognized in other populations
(e.g., substance use, depression treatment) that the
therapeutic alliance and therapist factors have a pro-
found impact on treatment (Barber et al., 2001; Horvath,
2001; Martin, Garske, & Davis, 2000), suggesting that
these issues may also be important in the treatment of
eating disorders.
7MI and CBT for Eating Disorders
Specifically, it has been suggested that understanding
the match between therapist behavior and patient
readiness to change may help explain why psychological
treatment for eating disorders is effective for only half of
those who initiate it. It is hypothesized that if the
intervention and readiness to change do not match,
damage will be done to the therapeutic alliance, resulting
in treatment failure (Miller & Rollnick, 2002; Prochaska,
DiClemente, & Norcross, 1992). Although much of the
initial research on readiness to change used smoking as
the problem behavior, it has been applied to a variety of
health behaviors, including alcohol and drug use,
gambling, exercise, sunscreen use, condom use, weight
loss and obesity, and, more recently, eating disorders.
Research in the eating disorders suggests that assessing
readiness to change before determining a treatment plan
allows clinicians to better match patients to treatment
modalities in the most cost-effective and time-efficient way
possible (Franko, 1997). Moreover, readiness to change
has been shown to predict weight gain, completion of
activities related to recovery, dropout, relapse, and the
decision to enroll in intensive eating disorder treatment
(Bewell & Carter, 2008; Geller, 2002a; Geller, Cockell, &
Drab, 2001; Geller et al., 2001, 2004; Reiger et al., 2000).
Application of MI to Eating Disorders
Patient dropout and noncompliance with treatment
recommendations are significant problems limiting the
effectiveness of many types of mental health treatments.
Because failure to comply with and complete treatment
can result in a number of negative consequences—most
importantly, poor treatment outcome—efforts to increase
compliance are under way in many areas of health
behavior change. Specifically, a search to understand the
critical conditions that are necessary and sufficient to
bring about behavior change has begun. In other
populations, research has shown that the match between
patient and therapist expectations about treatment
influences clients’ motivation to change. For instance, a
collaborative relationship between therapist and client
that encompasses a shared understanding of the goals
and tasks of therapy has been shown to consistently
predict better client outcomes (as cited in Moyers, Miller,
& Hendrikson, 2006). Conversely, a confrontational
therapeutic style has been associated with higher rates
of relapse than treatments using a patient-centered
therapeutic style (Miller, Benefield, & Tonigan, 1993).
Similar findings have emerged in the eating disorders:
collaborative treatment approaches were rated by both
clients and therapists as more likely than directive
treatment approaches to retain patients in treatment
and to promote adherence with treatment recommenda-
tions (Geller, Brown, Zaitsoff, Goodrich, & Hastings,
2003). Interestingly, in the aforementioned study, despite
participants’ clear preference for collaborative interven-
tions, directive interventions were rated as equally likely to
occur in practice.
Motivational interviewing (Miller & Rollnick, 2002) was
developed to address these treatment challenges and to
enhance readiness and motivation for recovery in
populations described as ambivalent about change. One
of the goals of MI is to help individuals increase their level
of readiness to change by combining elements of style
(e.g., warmth and empathy) and technique (e.g., key
questions and reflective listening). Clinician stance is
considered to be critical to MI, such that the therapist uses
a curious, nonjudgmental approach and shows genuine
interest in the patient’s experience of the problem. This is
consistent with other approaches advocating the impor-
tance of a curious, Socratic questioning style (e.g.,
Vitousek et al., 1998; Wilson & Schlam, 2004). Preliminary
work on the efficacy of adaptations of MI to individuals
with eating disorders has been promising (Cassin, von
Ranson, Heng, Brar, & Wojtowicz, 2008; Dunn, Neighbors,
& Larimer, 2006; Feld, Woodside, Kaplan, Olmstead, &
Carter, 2001; Geller, Brown, Srikameswaran, & Dunn,
2006; Treasure et al, 1999).
Clinical Illustrations
One of the strengths of MI is its consideration of patient
readiness in developing shared treatment goals. That is,
rather than basing treatment decisions primarily or
exclusively on symptom severity, motivational approaches
advocate the need to assess for, and match treatment to,
patient readiness. For this reason, in considering applica-
tions of MI to the treatment of eating disorders, four
patient scenarios involving individuals with varying degrees
of readiness, and in the context of different treatment
settings, will be addressed. These scenarios, which com-
monly occur in clinical practice, include:
• Newly assessed patients
• Patients enrolled in intensive, symptom-reduction
treatment programs
• Individuals with enduring eating disorders
• Individual outpatients with a fluctuating treatment
response
For each patient scenario, key issues will be described
and common roadblocks to the therapeutic alliance will be
provided. Clinical vignettes will be used to illustrate
conversations between patient and therapist for each
scenario, highlighting how MI can promote a working
therapeutic relationship and enhance long-term outcome.
Newly Assessed Patients
During an initial intake assessment, forming an alliance
and establishing a working therapeutic relationship is of
8 Geller & Dunn
central importance in obtaining accurate information and
increasing the likelihood that the patient will return for
future treatment. Interestingly, research has shown that
clinicians who conduct intake assessments and who are
responsible for making treatment recommendations
commonly overestimate patient readiness status (Geller,
2002b). Despite presenting for an initial assessment,
patients are not always ready to change their eating
behaviors. They typically come to their first sessions with a
number of concerns and assumptions; in some cases, they
may attend the session because they are forced or coerced
into doing so by a family member or partner. Some
patients may fear that they will be expected to make
changes for which they are not yet ready, some will be
interested in feeling better but not in giving up their eating
disorder behaviors, and others may wish to give up some,
but not all, of their eating disorder behaviors. Therapist
inaccuracy in assessing patient readiness may be due to the
challenge of providing a neutral environment that conveys
no expectations for change. MI offers a useful stance and
questioning approach, which helps dispel patient fears
about therapist expectations and increases trust in the
therapist as an ally, worthy of engaging with in an honest
relationship.
Common roadblocks/barriers:
• Making an assumption that the patient is ready for
change
• Failing to validate the difficulties of change
• Prompting the patient to talk about reasons for, but
not against, change
• Having an overly rigid agenda, which conveys a
power differential and can interfere with developing
a shared understanding of the problem
Example
The following encounter occurred in the context of
an initial psychosocial assessment with an adolescent at
a voluntary eating disorder treatment program. Prior
to making treatment recommendations, the assessor
met with Lisa to review her history of eating and
comorbid psychiatric problems.
THERAPIST (summarizing what Lisa has said thus far):
Thanks for explaining how your eating disorder devel-
oped and for describing what you are currently struggling
with, particularly how volatile things have been at home. It
sounds like it has been really tense, especially at meal
times. Is there anything else you think would be important
for me to know at this time to better understand your
situation and what might help you?
PATIENT: Just that everyone, especially my mom, is
making a way bigger deal out of this than they need
to. I don’t see what the problem is. I get my work
done and I feel fine. Why can’t everyone just leave me
alone?
THERAPIST: Yeah… it seems like one of the biggest
struggles has been dealing with others who see a problem
and who are pressuring you to change something that
actually feels okay for you right now.
PATIENT: Yes! I feel better than I have in a long time. I
never used to like my body and I had no self-confidence.
Now I like how I look; I wear cuter clothes.
THERAPIST: So there have been some real benefits to
cutting back on your eating with regard to your self-
esteem and body image. Are there any other advantages
to the changes you have made to your eating?
PATIENT: Well, I feel healthier and I’m getting
compliments from people who never used to notice me.
THERAPIST: So feeling better and getting positive
attention has also been rewarding. It must be really
frustrating for you when others, like your mom, give you a
hard time when this is working for you in so many ways.
PATIENT: Yeah, that pretty much sums it up. I wish
everyone who is hounding me about this could under-
stand that.
After further discussion, including a detailed assess-
ment of Lisa’s medical and psychiatric risk, which are
currently low, she and the therapist agreed upon a set of
treatment recommendations. These included attending
an outpatient group that provides information about
available treatment options, explores ambivalence about
change, and helps patients learn about the function that
eating disorders serve. It was also recommended that she
attend the program’s outpatient medical clinic, to
monitor her physical symptoms.
It is likely that with a patient like Lisa, attempting to
convince her of change at this stage would be unproduc-
tive and would make the therapist seem similar to others
who have been unhelpful. A common trap is to get pulled
into a confrontation where, as the therapist argues for
change, the patient becomes more dogmatic about
reasons for not changing. It is important to note that
taking a curious stance does not preclude the therapist
from informing the patient about health risks of her
current behavior(s) or the benefits of normalized eating.
Rather, investing time at this early stage to ensure that the
patient feels that her perspective is heard, understood,
and considered in making treatment recommendations
increases the likelihood that she will engage in any
9MI and CBT for Eating Disorders
treatment that is offered and maintain a positive regard
for the treatment team.
Patients Enrolled in Intensive, Symptom-Reduction
Treatment Programs
Different issues emerge for patients who have made
the decision to enroll in action-oriented, symptom-
reduction treatment programs. Residential treatments
typically require patients to adhere to a set of treatment
nonnegotiables, or mandatory treatment components, to
reduce eating disorder behaviors. In group programs the
therapeutic milieu is an important factor in promoting
change, as recovery among group members is enhanced
by patients entering into treatment voluntarily, prepared
to engage in change behavior. In such situations, patients
encourage and challenge one another to work on
recovery, reducing the need for the therapist to act as a
cheerleader for change. Given that research has shown
that long-term outcomes are more favorable when
patients make the decision to enroll in treatment for
themselves, as opposed to for others (Geller et al., 2004), a
motivational approach can be useful in preparing such
individuals for treatment, helping them to determine
when they are ready to enroll and ensuring that treatment
nonnegotiables are developed and enforced in a collab-
orative, consistent manner.
Common roadblocks/barriers:
• Admitting patients into action-oriented treatment
who are not invested in change
• Admitting patients who state that their primary
reason for enrolling in treatment is for others
• Failure to acknowledge and explore ambivalence as
it arises
• Nonnegotiables that have a poor rationale or are
inconsistently applied
Example
The following encounter occurred in the context of a
voluntary admission to a residential treatment program.
Prior to entry, Greta participated in an outpatient
preparatory program designed to assist patients in
determining whether they are interested and willing to
participate in the program, which has a number of
mandatory treatment components (e.g., abstinence from
bingeing and purging in the residence, minimum amount
of weight gain in a specified time period). As part of the
admission process Greta met with her therapist to review
the program nonnegotiables and discuss those aspects of
treatment that are individualized to each patient (e.g.,
activity protocol). The example below took place 1 week
prior to a program “critical week” in which Greta is
required to have gained a minimum amount of weight in
order to remain in program.
THERAPIST: How did things go with your weigh-in
today?
PATIENT: Umm… not that well. I didn’t make my gains.
THERAPIST: Hmm… so that makes next week your
“critical week.” What will that mean for you?
PATIENT: Well, it means I need to gain what I was
supposed to gain this week plus what I need to gain next
week, or else I’ll be asked to step-out from program.
THERAPIST: So this is an important time for you. How
are you feeling about all this?
PATIENT: Well, I know I have been skimping a little on
weekends… and maybe exercising a little more than what
my protocol says… but I didn’t think I was doing that badly.
I was actually surprised that with all the eating I’ve been
doing, I hardly gained anything!
THERAPIST: Yeah… it sounds like you’ve been
working pretty hard; you’re also aware of some things
that you could have done differently to increase the
likelihood that you gained the necessary weight this week.
What are your thoughts about next week?
PATIENT: I just don’t know if I can gain that much
weight! I mean… that’s a lot for me! I’m already struggling
with feeling fat…
THERAPIST: This really is hard work. What would it be
like for you if you don’t gain the weight next week?
PATIENT (softly): Well, if I don’t, I will have to take the
step-out and then maybe go home…
THERAPIST: (mirroring the patient’s softer tone of voice):
Mmm… and how would that be for you?
PATIENT: Well, I don’t really want that. I mean, I have
been struggling with the physical changes, but there have
been some good things about being here too — having a
break from my rituals and also getting some time away
from my mom have been helpful.
THERAPIST: So this really is a tough situation for you:
on the one hand, it would be a huge battle to make this
weight gain, but on the other hand leaving program
would also be difficult. What are your thoughts on where
to go next?
After considering her options, Greta decided to work
hard to make the necessary gains to stay in treatment. She
10 Geller & Dunn
asked her therapist to help her come up with strategies
that would assist her in doing so (e.g., staying at the
residence for meals on weekends instead of going home
and sticking to her exercise protocol by exercising only
when with a “buddy”).
This encounter illustrates the benefit of preparatory
work prior to entry into treatment. Because Greta was
informed about and agreed to adhere to the program
non-negotiables prior to coming into the program, she
was fully aware of her options, and the therapist’s role
was simply to assist her in choosing the best option for
her at this time. The development of sound treatment
nonnegotiables allows the therapist to avoid getting
caught in a convincing role and instead (s)he can focus
on helping the patient navigate the non-negotiables,
while acknowledging that there may not be any easy or
perfect choices available. Similar to the previous
example, this is another situation where attempting to
“cheerlead” or convince Greta to make changes may
backfire and result in her actually becoming less
committed to treatment.
Individuals With Enduring Eating Disorders
A particularly challenging group of patients are those
with longstanding eating disorders who have made several
unsuccessful treatment attempts in the past or who state
that recovery is not a goal for them. Unfortunately, such
patients often report a history of negative experiences
with care providers and can be especially difficult to
engage. These patients often present with the additional
challenge of becoming medically unstable and are often
unwilling to be admitted to hospital to ensure their
medical safety. In dealing with such patients, it is
common for conflicts to arise. MI can be extremely
useful in these cases by providing a stance and set of
principles that involves reviewing what hasn’t worked in
the past, fostering establishment of new, shared goals,
and maintaining a therapeutic alliance while working
with treatment nonnegotiables, or mandatory treatment
components.
Common roadblocks/barriers:
• Repeating interventions/approaches that have
failed in the past
• Overusing directive or threatening interventions
• Failing to maximize patient autonomy
• Failing to identify and work with patient higher
values
• Treatment team not working together
Example
Leanne has been battling severe AN for the past 20
years. She has been repeatedly admitted to specialized
intensive treatment programs. Each time, although she was
able to gain weight while in program, she immediately
relapsed upon discharge. Currently, Leanne is losing
weight and once again her physician is threatening
certification (an involuntary treatment admission). The
conversation below took place after Leanne heard this
news.
THERAPIST: I understand that Dr. Chan is really
worried about your health.
PATIENT: Yeah, I lost more weight last week and I’ve
been feeling a bit light-headed lately. But it’s really not that
bad…
THERAPIST: So, you have some physical challenges
right now, but aren’t too concerned.
PATIENT: No… but I know my doctor is, because she
told me that if I don’t show up for outpatient meal support
twice a week she will make me come into hospital.
THERAPIST: I see… so she must be thinking this is a bit
more serious. This seems like a good time to check in
about what you want. How do you feel about being
admitted to hospital involuntarily?
PATIENT: (exasperated): I’ve done that so many times
before and it never helps in the long run. I hate having no
control over when or how the admission happens and
being stuck in the hospital with no freedom… I also hate
being policed all the time!
THERAPIST: Yeah… the loss of freedom can be really
hard. Is there anything else that would be difficult about
an involuntary admission?
PATIENT: Well, I’d have to give up everything that I
care about; I wouldn’t be able to do my volunteer work or
finish the course that I’m taking.
THERAPIST: That does sound tough. I know you’ve
really been enjoying your time volunteering at the
daycare and that giving back to the community is really
important to you. You’ve also said that you have wanted to
finish your degree for some time now.
PATIENT: Yeah, if I dropped those things now I would
be letting everyone down, with basically no warning. That
is not who I want to be… and would make me feel like a
failure.
THERAPIST: So getting certified would be really
devastating for many reasons. How have those types of
admissions gone for you in the past?
11MI and CBT for Eating Disorders
PATIENT: Well, I think it’s kind of useless, since no
matter how many gains I make while in hospital, it’s not
because of anything I am doing, you have to! So I don’t
have any confidence that I can maintain the changes after
I leave.
THERAPIST: And what, if any, changes would you
ideally like to maintain after you leave?
PATIENT: Honestly, I’d just like to avoid being
certified again so that I can carry on with my life. It is so
disruptive not being able to plan more than a few days
ahead… but I do know that I need more energy so I can
play with the kids when I’m volunteering.
THERAPIST: It sounds like what would be most
helpful for you right now is to avoid being certified. Is
that something you’d like to work on?
PATIENT: I guess. It’s something I’ve never been able
to do before.
In this encounter, the therapist was invested in helping
Leanne avoid having another unhelpful treatment experi-
ence, rather than on weight gain or other symptom change.
Although at first glance it may be difficult to see the value of
taking this kind of stance with a patient who is clearly on the
verge of medical instability, this sort of initiative can have a
profound effect on the therapeutic alliance, as well as
increase the patient’s feelings of autonomy and self-
efficacy. These, in turn, have beneficial effects for short-
and long-term treatment outcome, as the patient is more
likely to engage in treatment and maintain changes over
longer periods of time. In this example, the therapist was
also interested in the patient’s higher values, such as
participating in volunteer work or completing her degree.
This type of inquiry helps ensure that both patient and
therapist stay connected to the patient’s overarching goals
and also increases trust in the therapeutic relationship.
Following this encounter, Leanne was more open with
the treatment team and, over the weeks that followed, in
collaboration with the rest of her care providers, Leanne
and her therapist worked out a plan for her to avoid
certification. This required her regular attendance at
outpatient meal support twice per week and a decrease in
her activity level. When a spot in the inpatient program
became available, Leanne was given the option to accept a
voluntary medical admission. The goals of the admission
were carefully agreed upon with her prior to coming in,
with a primary objective of identifying her barriers to
maintaining changes after discharge. Upon discharge,
Leanne reflected that this had been by far her most
helpful hospital experience and was eager to continue
working on improving her health.
Individual Outpatients With a Fluctuating
Treatment Response
Incorporating MI into cognitive behavioral work with
outpatients is useful, as there is typically a natural waxing
and waning of readiness over time. Even in strong working
relationships it is possible for therapists to become
frustrated with patient lapses in readiness. It is also common
for patients to become frustrated with therapists who
persevere with skill building when the patient has slipped
back a little and is wishing to address barriers to recovery.
Common roadblocks/barriers:
• Failing to recognize and/or address ambivalence
when it arises
• Assuming that the patient is equally ready to change
each behavior
• Focusing on skills when the patient has pressing
emotional issues that need to be addressed
• Assuming that low motivation to change is exclu-
sively due to lack of skill or competence
Example
The patient in the following example has BN and has
been working well in therapy over the past 12 weeks.
Using a CBT framework, she and her therapist have used
food monitoring records to identify her triggers for binge
eating and to increase her understanding of the factors
that maintain her eating disorder. Over the first 10 weeks,
Jane tracked her eating, purging, and exercise behaviors.
Upon learning that in addition to emotional triggers, Jane
also binged in response to chronic malnutrition, she
increased her meal plan to include three healthy meals
and two snacks each day. Whereas she was able to do this
for several weeks, in the encounter described below, Jane
has hit a roadblock. She states that she is feeling
discouraged with her progress and questions whether
she wants to continue with the work she has been doing.
THERAPIST: So, how did things go last week?
PATIENT: Well… I stuck to my meal plan and didn’t
purge for the third week in a row… but I don’t know,
maybe I’m burned out. I’m not feeling very good…
THERAPIST: Getting through another week without
purging is a real accomplishment. It also sounds like things
have been difficult. I’m curious about what else is going on?
It sounds like there have been some struggles.
PATIENT: Well… my clothes just aren’t fitting the way
they used to. And I’m not imagining it. When I got
weighed last week I had gained another pound. To be
honest I can’t help but wonder if this is all worth it.
12 Geller & Dunn
THERAPIST: Ah… you sound discouraged. Weight
gain is really hard. Can you say more about that?
PATIENT: Well… before I made these changes to my
eating I at least liked my body… I mean, I thought about it
all the time and that was a drag… but now I can barely
stand looking at myself in the mirror!
THERAPIST: So one thing you are struggling with is
that there have been some changes to your body since
eating more healthfully. I do remember you talking about
how your physical appearance has been a source of
concern for you, so that does sound difficult. It would be
good for us to talk about that more. Before we do, though,
I want to make sure that I get a good understanding of
everything you’re going through. Are there any other
things that are making you wonder whether this work that
you are doing is worth it?
PATIENT: Yes… I mean, I know it might not have been
the healthiest way of coping, but before, when I binged, it
was a total escape from the world and my problems. I
always had a way to take a little vacation from everything,
Now I get stressed out about something and I have to just
sit with all these feelings… I don’t like that! It was a lot
easier before!
THERAPIST: Ah… so another huge adjustment you are
going through, and a really difficult one, is that as a result
of no longer bingeing you are experiencing strong
feelings with no immediate escape. Can you say more
about what sorts of things are bringing up these feelings?
PATIENT: Well, last week I had a few days that I worked
overtime and still didn’t feel like I had accomplished
everything I set out to do. Also, I’m still having trouble with
my boss. By the time I got home I was so tired and fed up, I
just wanted to tune the world out… but couldn’t.
THERAPIST: Ah… that would have been a time when
in the past you would have binged. We learned that from
your monitoring records.
PATIENT: Yeah…
THERAPIST: So this has been a really tough week: you
are struggling with some possible physical changes and
you are really missing the escape that bingeing and
purging used to provide, especially when things are
stressful for you at work. That’s quite a lot to deal with and
I’d like to help you understand those things better and
figure out what is the best path for you. Before we do,
though, is there anything else that you’re aware of that is
causing you to question continuing with treatment?
PATIENT: Ummm… No, I think those are the two main
things. Well… there was one other time I was supposed to
go out for dinner with a friend and she cancelled. I was
feeling lonely and I wanted to binge as a way to keep
myself company and pass the time…
THERAPIST: Ah… so you have also used bingeing as a
way of helping pass the time when you are feeling low…
PATIENT: (nods)
THERAPIST: This really has been a difficult week.
Was there anything else that you are aware of that
happened to make you feel unsure about this work you
are doing?
PATIENT: No. I think that’s it.
THERAPIST: Well, that is certainly a lot! One option
would be for us to talk about ways to help you deal with
some of these body image concerns that you are having,
and with missing the relief that bingeing and purging has
provided… but it sounds like there is a bigger issue or
concern for you, which is whether this recovery process
you are going through is worth it to you.
PATIENT: Yeah, well, up until now I thought it was
really hard but that I was doing well! I expected that by
now, after all this time, it would get easier…
THERAPIST: So part of this is being surprised and
frustrated that it’s been such a tough journey…
PATIENT: Yes.
THERAPIST: Unfortunately, it is experienced that way
by many people who go on to recover. You’re certainly not
alone in having struggles at this stage. In fact, this is a
turning point for many people who have to decide
whether they want to persevere when they begin
encountering setbacks, even after accomplishing so
much. What are your thoughts about how you would like
to proceed?
PATIENT: Like I said — I just don’t know if I want to
keep doing this. I want my old body back!
THERAPIST: Okay, to help you make the most
informed decision, how about we explore what stopping
at this point would be like for you. I’m curious what you
anticipate would happen…
PATIENT: Well, for one thing, I would lose weight and
not feel so full all the time.
13MI and CBT for Eating Disorders
THERAPIST: And how would that be?
PATIENT: It would be great! I wouldn’t feel so bad
about my body.
THERAPIST: Is that how you remember things being
before? That you felt good about your body?
PATIENT: Well… I guess I did still think about it a lot…
and I was always trying to lose weight…
THERAPIST: Ah… so your feelings about your body
may or may not improve if you stopped treatment. What
else do you remember about your life when your bingeing
and purging was more active?
PATIENT: Well… I did feel a little bit like my life was
out of control and like I was consumed with thoughts of
food all the time. That made me feel like there was
something wrong with me…
THERAPIST: Hmm… those sound like hard things to
cope with also…
PATIENT: They were…
THERAPIST: So this is a tough spot for you. On the
one hand, things are really hard for you right now —
you’ve made these fantastic changes but it’s a lot of work
and there are some consequences to it, like changes to
your body.… On the other hand, going back to the way
things were before is also pretty tough — you had to live
with feeling out of control, consumed with thoughts of
food, and even though your body may have been a little
different, you still felt dissatisfied.
PATIENT: Yeah… that’s true. It seems like there are no
easy paths…
THERAPIST: I’m afraid not. Given the difficulty of
both paths, which do you think fits best, or feels most
right, for you now?
After further discussion, Jane decided that despite the
challenges she was encountering she wanted to continue
with therapy. After reviewing her situation further, she and
her therapist decided to address some of the difficulties
she was having with body image by decreasing the
challenging foods she was incorporating into her meal
plan and starting to work through exercises geared toward
improving body image. They also focused on expanding
Jane’s repertoire of coping strategies, such as continuing
to reach out to friends when she is lonely and experiment-
ing with other ways to appropriately unwind or distract
herself from some of the stresses in her life.
Had the therapist taken a different approach and
instead attempted to convince Jane to remain in
treatment without fully exploring Jane’s difficulties and
concerns, it is possible that Jane might have reacted by
passively agreeing to assignments but not following
through with them or by trying to persuade the therapist
to see how difficult and unfulfilling change really is.
Instead, Jane said she felt understood, a renewed sense of
trust in her therapist, and less alone in her journey after
this conversation.
Conclusions and Future Directions
A primary strength of CBT is its action-oriented nature;
it seeks to identify and address the functions of eating
disorder behaviors and to replace them with healthier,
more adaptive functioning. The difficulty that arises is
when patients are not yet ready to relinquish their eating
disorder and are thus not fully engaged in this process. MI
has much to contribute to CBT in these cases, as it
explicitly focuses on enhancing patient readiness and
maximizing treatment efficacy by ensuring that skill
building occurs when the patient is most receptive.
Using an MI stance ensures that treatment providers and
patients are working together on shared goals, thus
maintaining an alliance throughout the bumps of therapy.
Although a skillful CBT therapist (or indeed practitioner
of any treatment modality) may intuitively manage their
pacing and interventions to patient readiness using similar
strategies, MI makes these goals explicit and provides a
language and set of techniques to assist in the process.
To date, the majority of research on MI in the
treatment of eating disorders has focused on its use as a
pretreatment to CBT or to other intensive treatment
(Cassin et al., 2008; Dunn et al., 2006; Geller et al., 2006;
Treasure et al., 1999). For instance, recent study results
(Dunn et al., 2006; Cassin et al., 2008) suggest that the use
of a brief MI add-on to self-help intervention for binge
eating may be a potentially cost-effective treatment. That
is, MI enhancement was shown to only slightly increase
the total time of face-to-face care, but resulted in
improved outcome that was comparable to that found
after 4 hours of motivation enhancement therapy
(Treasure et al., 1999) and 4 months of CBT (Wilfley et
al., 1993). Although many of the interviewers in these
studies were undergraduate or graduate research assis-
tants who received only a few months of training in the
theory and techniques of MI, they were nevertheless
comparable to master-level therapists in participant
satisfaction and adherence ratings.
MI has also been shown to have utility with individuals
who have severe eating disorders. In a tertiary-care clinical
setting, a brief 5-session MI-informed treatment offered
following a standard intake assessment significantly
reduced the number of highly ambivalent individuals
14 Geller & Dunn
posttreatment and at 3-month follow-up (Geller et al.,
2006). As previous research demonstrated that these
highly ambivalent individuals were more likely to drop out
or relapse following intensive therapy (Geller et al., 2004),
this research suggests that incorporating MI strategies
into the menu of treatment options may significantly
improve long-term outcome in these clinical settings,
where intensive treatment is expensive (Geller et al.,
2006).
Despite promising preliminary results, more research
is needed to investigate the efficacy of motivational
enhancement techniques as stand-alone or adjunct
interventions in the treatment of eating disorders. In
addition, given that motivational issues are recognized as
pertinent throughout treatment in this population (e.g.,
Fairburn, 2008), understanding the mechanisms by which
motivation develops and is maintained would also be
useful. Very little is currently known about the eating
disorder populations for whom MI works best. Future
studies should attempt to answer this question by
examining differential responding by individuals with
different baseline readiness, eating disorder diagnoses
and/or severity, as well as for eating disordered men.
Finally, given that family members are often experienced
by patients as overly directive in regards to behavior
change, teaching MI techniques to family and friends of
individuals with eating disorders may also be of great
benefit (Treasure et al., 2007).
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This research was supported by a senior scholar grant awarded to the
first author from the Michael Smith Foundation for Health Research.
Address correspondence to Erin C. Dunn, Ph.D., Eating Disorders
Program, St. Paul’s Hospital, Psychiatry, 1081 Burrard St., Vancouver,
BC V6Z 1Y6 Canada; e-mail: edunn@providencehealth.bc.ca.
Received: January 14, 2009
Accepted: May 3, 2009
Available online 2 April 2010
mailto:edunn@providencehealth.bc.ca
Treatment of Eating Disorders
Treatment Dropout and Failure to Engage
Application of MI to Eating Disorders
Clinical Illustrations
Newly Assessed Patients
Example
Patients Enrolled in Intensive, Symptom-Reduction Treatment Programs
Example
Individuals With Enduring Eating Disorders
Example
Individual Outpatients With a Fluctuating �Treatment Response
Example
Conclusions and Future Directions
References
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Laureate
Education,
Inc.
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Eating Disorders and Body Image
There have been a number of changes from the DSM-IV to the DSM-5 related to
classification and description of these disorders. First, categories have been
expanded and disorders grouped according to similarities observed in manifestation
and expression.
Feeding and Eating Disorders
This new DSM-5 classification includes diagnoses formerly included under eating
disorders and disorders usually first diagnosed in infancy, childhood, and adolescence.
This group of disorders is defined by the similarities in disruption to normal eating
behaviors. It includes pica, rumination disorder, avoidant/restrictive food intake disorder,
anorexia nervosa, bulimia nervosa, binge-eating disorder, other specified feeding or
eating disorder, and unspecified feeding or eating disorder.
Two of these diagnoses are new to the DSM-5: other specified feeding or eating
disorder and unspecified feeding or eating disorder. These take the place of eating
disorder NOS in the DSM-IV, which has been removed in the DSM-5. Both of these
diagnoses represent significant clinical distress or impairment based on criteria for
feeding or eating disorders but do not meet full criteria for a specific diagnosis in this
class. Clinicians should use other specified feeding or eating disorder and add the
specific reason for the more general diagnosis (e.g., weight or compensatory
behavioral observations which vary from specific diagnostic criteria). The latter
diagnosis—unspecified feeding or eating disorder—is used when clinicians cannot (or
choose not to) identify reasons for the inability to make a more specific diagnosis yet
clearly observe multiple criteria from the feeding and eating disorders classification.
The following is a brief summary of key changes to diagnoses in this group.
Pica
The diagnostic criteria for pica remain largely unchanged in the DSM-5. The most
significant change is the recognition that the diagnosis can be made in both children and
adults—previously, it had been included in the chapter on disorders usually first
diagnosed in infancy, childhood, and adolescence. A remission specifier has also been
added.
Rumination Disorder
The diagnostic criteria for rumination disorder remains largely unchanged in the DSM-
5, with the exception that Criterion C from the DSM-IV has been divided into two
separate criteria with language added for clarity. In addition, the DSM-5 includes the
recognition that the diagnosis can be made in both children and adults—previously, it
had been included in the chapter on disorders usually first diagnosed in infancy,
childhood, and adolescence. A remission specifier has also been added.
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Avoidant/Restrictive Food Intake Disorder
This new diagnosis takes the place of feeding disorder of infancy or childhood, found in
the DSM-IV. The criteria have been considerably expanded, to include symptoms
related to weight, behavior, physical health, and psychosocial functioning. Differential
diagnosis now includes reference to other disorders and medical conditions. Lastly, a
specifier that pertains to remission status has been added.
Anorexia Nervosa
Descriptions found under this diagnosis have been expanded considerably, though
the core symptomology remains unchanged. For example, Criterion A has been
revised for clarity, reflecting the manifestation of symptoms related to weight. In
addition, Criterion D from the DSM-IV has been entirely removed; this criterion
included the requirement of amenorrhea. Lastly, remission specifiers have been
added as well as specifiers linking severity with body mass index (BMI).
Bulimia Nervosa
The diagnostic criteria for this disorder in the DSM-5 are nearly identical to those found
in the DSM-IV, with two noted exceptions: First, Criterion C now includes once per week
for 3 months as the threshold duration. Second, severity specifiers that are directly
related to frequency of compensatory behaviors have been added.
Binge-Eating Disorder
This is a new disorder in the DSM-5, having been moved from Appendix B of the DSM-
IV following extensive research. The minimum frequency is different from that noted in
the DSM- IV; the DSM-5 notes that the binge eating must occur an average of once per
week for 3 months.
Obsessive-Compulsive and Related Disorders
This classification—new to the DSM-5—recognizes the similarities in presentation and
diagnostic criteria of disorders characterized by obsessions and/or compulsions. The
former refers to thoughts that are persistent and intrusive, while the latter denotes
behaviors an individual feels compelled to perform. This group of disorders is examined
more in depth with the topic of fears, phobias and anxieties. However, one diagnosis
with this group is included with this week’s topics, as it relates to concepts of self-
perception, often associated with eating disorders and body image.
Body Dysmorphic Disorder
This diagnosis has been moved from the somatoform disorders to this new classification
and several criteria altered, including specifications for repetitive behavior and
preoccupied thoughts. In addition, a specifier of “with muscle dysmorphia,” which
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denotes a persistent belief that the individual’s body is insufficiently developed in size
and/or musculature, has been added. The inclusion of the “absent insight/delusional
beliefs” specifier when applicable eliminates the potential for a second diagnosis of
delusional disorder, somatic type that was possible under DSM-IV diagnostic criteria.
Reference:
• American Psychiatric Association (2013). Highlights of changes from DSM-IV-TR
to DSM-5. Retrieved from
http://www.dsm5.org/Documents/changes%20from%20dsm-iv-
tr%20to%20dsm-5
Article
Family-Based Therapy for Pediatric
Anorexia Nervosa: Highlighting the
Implementation Challenges
Jennifer Scarborough
1
Abstract
Family-based therapy is a recommended treatment for children and adolescents diagnosed with an eating disorder. Despite the
promising results, this model is not without its challenges. Through literature review and treatment exemplars, this article
provides a brief overview of family-based therapy and highlights the many challenges for clinicians and parents implementing this
therapy. Noted challenges are barriers to clinical supervision, inadequate treatment options, time and finances, relationships, and
parental adjustment. This article concludes with implications for research and clinical practice.
Keywords
eating disorders, family based therapy, pediatric, maudsley, anorexia nervosa
Eating disorders have the highest mortality rate of any mental
illness, with 10–20% of individuals succumbing either to the
medical complications of the disorder or to suicide (Crow et al.,
2009; Fisher, 2006; Harris & Barraclough, 1998; Nielsen,
2001). The illness generally presents between the ages of 13
and 19; a time when an adolescent is still usually dependent on
their parents but is also experiencing greater autonomy (Scott,
Biskman, Woolgar, Humayun, & O’Connor, 2011; Smick, van
Hoeken, & Hoek, 2012; Weaver & Liebman, 2011).
Eating disorders can be difficult to treat. This is partly due
to the diagnosed individual’s inability to understand the
severity of their illness (Fisher, Schneider, Burns, Symons,
& Mandel, 2001). Thus, the involvement of parents can
greatly increase the chances of successful recovery (Golan
& Crow, 2004). Family-based therapy is currently a fre-
quently recommended treatment for children and adolescents
diagnosed with an eating disorder (American Psychiatric
Association, 2006; Findlay, Pinzon, Taddeo, & Katzman,
2010; Mitchum, 2010).
Although family-based therapy is a highly recommended
treatment, this intervention is not without its challenges. Pre-
sently, family-based therapy does not explicitly acknowledge
the additional pressures that parents face when engaged in
treatment. Everyday family demands (e.g., finances, relation-
ships) become more challenging with the added demands and
expectations of treatment.
The aim of this article is to highlight the many challenges
that are encountered when attempting to implement family-
based therapy. Understanding these issues is vital for success-
ful implementation. Exploring the potential barriers for parents
and clinicians is necessary in order to improve the chances of
successful implementation of family-based therapy as well as
longevity in treatment. This article is intended to help clini-
cians gain a better understanding of these pressures on parents
and to support their discussions with parents as well as open a
dialogue on the challenges faced in family-based therapy. In
addition, this article will help researchers develop a better
understanding of the parental experience when caring for an
adolescent diagnosed with an eating disorder as well as the
challenges of implementing family-based therapy.
This article begins with a brief overview of family-based
therapy to provide context and a general understanding of
manualized family-based therapy and its expected outcomes.
This is followed by an explanation of the procedures used in
identifying issues such as (1) training and adherence to family-
based therapy, (2) inadequate treatment options, (3) time and
finances, (4) relationship maintenance, and (5) parenting
adjustment and eating disorder resistance. Each discussion of
an issue is supported by literature and illustrated by an exem-
plar from family-based therapy practice. The article concludes
with a discussion of implications and suggestions for
improvement.
1
Faculty of Social Work, Wilfrid Laurier University, Kitchener, Ontario,
Canada
Corresponding Author:
Jennifer Scarborough, Faculty of Social Work, Wilfrid Laurier University, 120
Duke St. W., Kitchener, Ontario, Canada N2H3W8.
Email: jscarborough@wlu.ca
The Family Journal: Counseling and
Therapy for Couples and Families
2018, Vol. 26(1) 90-98
ª The Author(s) 2018
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Overview of Family-Based Therapy
This overview section is provided to inform readers of family-
based therapy and the role parents play in this treatment.
Family-based therapy is a treatment that encourages and moti-
vates parents to facilitate their child’s recovery by preparing
and supervising meals. Family-based therapy is a weekly out-
patient treatment that is nondirective in nature. The therapist is
more of a consultant asking parents questions to empower them
to arrive at decisions to fight the eating disorder. The purpose
of family-based therapy is to intervene to decrease the chances
for hospitalization.
Families were first included in the treatment of eating dis-
orders by Minuchin and his colleagues (Minuchin, Rosman, &
Baker, 1978). Due to their relative success with the inclusion of
families in treatment, Minuchin developed the model of the
psychosomatic family, which believed that familial dysfunc-
tions or enmeshments lead to disordered eating behaviors. In
addition to Minuchin’s structural family therapy, both the
Milan group and strategic family therapy influenced the devel-
opment of family-based therapy, which led to controlled stud-
ies conducted at Maudsley hospital in London (Loeb & Le
Grange, 2009).
Family-based therapy was eventually manualized by James
Lock, Daniel Le Grange, and colleagues in 2001. They have
since published a manual for bulimia nervosa and a second
edition of the original manual for anorexia nervosa. Family-
based therapy has specific components. These components are
that the therapist take an agnostic view of the illness, which
means that there are no assumptions as to what may have led
to the eating disorder onset. Since family-based therapy focuses
on what needs to be done in the present to quickly move forward
in recovery, the exploration of potential causes is not examined.
Another component of family-based therapy is externalization
of the illness. Additionally, parental empowerment is a key
feature, whereby the therapist is nonauthoritative and acts more
of a consultant to parents to guide and support them in aiding
their child to recovery (Lock & Le
Grange, 2013).
Family-based therapy has a recovery rate of about 50–60%
at 6 and 12 months follow-ups, with recovery defined as reach-
ing >95% ideal body weight and within 1 standard deviation of
community norms on the Eating Disorder Examination Ques-
tionnaire (Lock et al., 2010). In family-based therapy, parents
are seen as “functioning similar to an effective inpatient nur-
sing staff—at least during the first phase of treatment—albeit
in the home setting” and are tasked with this role as they “love
their children, know them well, and are highly invested in their
[child’s] survival” (Le Grange & Lock, 2011, p. 230).
Family-based therapy consists of three phases with 15–20
sessions in total over 12 months. These three phases are (1)
weight restoration, (2) returning control to the adolescent, and
(3) establishing healthy adolescent identity (Lock & Le
Grange, 2013).
In Phase 1, weight restoration, the therapist supports parents
in the renourishing of their ill child. The second session in this
first phase involves a supervised meal session where the
therapist can view and assist parents in encouraging their child
to eat a meal the parents bring. Throughout Phase 1, the thera-
pist models a noncritical stance toward the ill child and con-
tinues to support the parents in the refeeding process.
Phase 2, returning control to the adolescent, takes place
when the child has begun to show signs of acceptance of
increased food intake from the parent as well as weight gain
and an overall positive change in mood. In Phase 2, the parents
begin to encourage and support their child to regain control
over their eating as developmentally appropriate. Weight gain
remains a focus in this phase.
Phase 3, establishing healthy adolescent identity, is indi-
cated by the adolescent reaching and maintaining a minimum
of 95% ideal body weight. This phase focuses on adolescent
autonomy and establishing developmentally appropriate
boundaries for parents.
While family-based therapy is considered by some the first
line of treatment for eating disorders, there are certain instances
where this treatment may not be appropriate. Firstly, children
who are medically unstable, or suicidal, should be hospitalized
and not begin treatment until stable. Parents with severe psy-
chopathology may also be contraindicated for the uptake of
family-based therapy (Le Grange, Lock, Loeb, & Nicholls,
2010). Despite this, Le Grange, Lock, Loeb, and Nicholls
(2010) mention the importance of family involvement even
in difficult circumstances:
the assessment of families requires close attention to the parents’
competencies, motivation, and history of adverse or traumatizing
events. But even when such adverse circumstances are present, the
development of a play to help and support sufferers and how to
ease family burdens should take precedence over accusation and
blame. Thus, it is our position that families should be involved
routinely in the treatment of most young people with an eating
disorder. Exactly how such involvement should be structured, and
how it will be most helpful will vary from family to family. (p. 4)
While not contraindicated, there are several factors that are
worth mentioning that need to be kept in mind when implement-
ing family-based therapy. Children over the age of 18 or who
have had the eating disorder for longer than 3 years may not fare
as well compared to younger and less chronic children (Le
Grange, 2005; Lock & Le Grange, 2013; Loeb & Le Grange,
2009; Rienecke, 2017). Adolescents with comorbid psychiatric
disorders have higher rates of treatment dropout and lower
remission rates (Lock, Couturier, Bryson, & Agras, 2006). Par-
ents who present as hostile or overly critical may be better suited
for a separated form of family-based therapy, whereby the thera-
pist meets with the child and parents separate from each other
(Dare, Hodes, Russell Dodge, & Le Grange, 2000).
Procedures
The origin of this article emerged from observations of family-
based therapy through clinical practice, supervision of other
clinicians implementing family-based therapy, and agency-
Scarborough 91
based challenges. Through these observations, a number of
implementation issues have been identified.
In addition to clinical practice observations, and conversa-
tions with parents, clinicians working in the field of pediatric
eating disorders have echoed these difficulties when applying
family-based therapy. Once themes had been identified, a com-
prehensive literature search and review was completed focused
on these issues.
Using Primo, a library catalog search procedure, the key
words “parents, caregivers, family-based therapy, Maudsley,
eating disorders, children” were used to find appropriate liter-
ature about family-based therapy implementation challenges.
Once this literature was reviewed, pertinent material was then
combined with the author’s practice experiences, leading to
the identification and discussion of issues and challenges
within the family-based therapy model as presented in this
article. To effectively convey family-based therapy chal-
lenges, the article is organized into sections containing a
review of literature pertinent to the issues identified, followed
with an exemplar from practice, supervision, or agency admin-
istrative experiences.
Family-Based Therapy Demands on Clinicians
Clinicians who are trained in family-based therapy are fortu-
nate to have the ability to implement the most up to date,
evidence-based treatment for families who have a child diag-
nosed with an eating disorder. Despite having formal training
in this therapy, there remain several challenges that have con-
sequences for clinicians and clients.
Family-based therapy training and adherence for clinicians. Current
evidence in the treatment of eating disorders for adolescents
shows that outpatient treatment using a family-based approach
is effective in returning adolescents to health (Lock et al.,
2010). For this reason, a training institute to ensure quality of
care and proper training in the use of family-based therapy in
practice has been developed (see Training Institute for Child
and Adolescent Eating Disorders, 2017).
In order to be considered a certified family-based therapy
therapist, 2 days of training and 25 hr of individual supervision,
with tape recordings of sessions and in-person or phone meet-
ings, must be completed. In Canada, there are only five fully
certified family-based therapy therapists listed on the Training
Institute for Child and Adolescent Eating Disorders website.
This lack of fully certified family-based therapy therapists is
not surprising, as many agencies are unable to fund their clin-
icians in the full course of certification. What often happens is
just the 2-day workshop (Level 1) is completed. Due to this,
clinicians are often attempting to implement family-based ther-
apy without supervision.
A study by Couturier et al. (2013) found that several of the
key aspects of family-based therapy were not being adhered to
in agencies, such as weighing the adolescent at the start of all
sessions as well as the family meal which takes place in the
second session of Phase 1. Reasons for not implementing
certain key aspects of family-based therapy were due to various
factors such as the clinician’s scope in practice (e.g., weighing
of the patient is viewed as a medical role) or by organizational
barriers such as a lack of space to complete family meals within
the agency. For these reasons, parents are provided with more
of an informed family-based therapy rather than the manualized
model. In some cases, many therapists are using therapeutic
techniques that are not suggested or recommended by the
family-based therapy manual (Kosmerly, Waller, & Lafrance
Robinson, 2015).
Parents are led to believe that they may be receiving the
recommended treatment; however, in order to confidently
expect outcomes similar to those indicated in research, the
manualized treatment protocol must be followed. One of the
major issues with this informed family-based therapy is that
there is a lack of data on mixing therapeutic techniques. This
informed family-based therapy may mislead parents into
believing that they are receiving the evidence-based treat-
ment. Should the therapy fail, these parents may end up
believing that the best treatment to date was not enough to
help them, when in fact they never received the manualized
treatment in the first place.
In addition to this, supervision of clinicians implementing
family-based therapy is vital given that clinician anxiety has
been shown to lead clinicians to stray away from evidence
based the protocol (Waller, Stringer, & Meyer, 2012). In fact,
eating disorder clinicians working with children and adoles-
cents reported that negative emotions impacted clinician deci-
sions (Lafrance Robinson & Kosmerly, 2014, p. 10).
Supervision does exist specifically for the clinical blockages
that may hinder treatment progression (Lafrance Robinson &
Dolhanty, 2013). However, some agencies may be unable to
access this supervision due to financial limitations.
Supervision of treatment implementation is necessary to
help clinicians be aware of judgments they may have when
working with families. Part of family-based therapy is main-
taining a nonjudgmental and nonblaming stance toward par-
ents. Yet Couturier et al. (2013) reported that some clinicians
had “little sympathies for families who do not attend appoint-
ments during normal work hours, because therapists feel fam-
ilies would not hesitate to attend if their child was diagnosed
with a serious physical illness (e.g., cancer)” (p. 182).
Exemplar. In the case of Sam, a 15-year-old female with
anorexia nervosa, a referral to an outside, private therapist to
treat her depressive symptoms was made as her parents felt that
these emotions were the precursor to the development of the
eating disorder. Sam’s family-based therapy clinician sup-
ported the parents’ decisions since the child was not engaging
with the family-based therapy clinician and thus was not get-
ting enough emotional support through the process.
In the family-based therapy protocol, it is recommended that
all other forms of counseling be halted while in treatment. The
reason for this is demonstrated in Sam’s case, where contra-
dicting messages were given from the private therapist about
the parents’ role in refeeding. The private therapist
92 The Family Journal: Counseling and Therapy for Couples and Families 26(1)
recommended that Sam’s parents stop preparing and supervis-
ing Sam’s meals as this was contributing to Sam’s depression.
Sam felt that she was being treated like a toddler. The private
therapist assured the parents that Sam had learned skills to cope
with the depressive thoughts, which were similar to the eating
disorder thoughts. The parents then withdrew from family-
based therapy treatment, so Sam could pursue her individual
treatment for depression. A closing letter from the family-
based therapy clinician to the family doctor recommended
medical monitoring.
Sam eventually returned to the eating disorder agency. Her
eating disorder behaviors never ceased and weight loss contin-
ued while in private treatment for depression. The private
therapist eventually discharged Sam from her care as the med-
ical urgency of her weight loss became too pressing. When Sam
and her family returned to the agency, a referral was made to an
inpatient eating disorder program as her weight loss was too
extreme to manage on an outpatient basis.
Inadequate treatment options. For anorexia nervosa, family-
based therapy has a nonresponse to treatment rate of 15–30%
(Krautter & Lock, 2004; Lock et al., 2010). Some of the mod-
erators identified as having an impact on the outcome are (1)
the eating disorder’s severity at clinical assessment, (2) diag-
nosed comorbidities, (3) being an older adolescent, and (4)
parents with high emotional expression (Dare, Eisler, Russell,
& Szmukler, 1990; Le Grange et al., 1992, 2012; Murray & Le
Grange, 2014).
In terms of nonresponse to family-based therapy, Doyle, Le
Grange, Loeb, Doyle, and Crosby (2010) found that the stron-
gest indicator for remission was a weight gain of 2.88% by the
fourth session (approximately 1 month into therapy) of the
manualized treatment. For patients unable to achieve this
weight gain, another treatment model may be required. A key
challenge for clinicians is the lack of treatment options and
training for these treatment models that currently exist. As a
result, clinicians may desperately try to continue to use family-
based therapy and not know when, or how, to switch to another
form of therapy (Steiger, 2017).
Other treatments do exist for adolescents, either as comple-
ments to boost family-based therapy effectiveness or as alter-
native treatments to family-based therapy. They include (1)
adolescent focused psychotherapy (see Fitzpatrick, Moye,
Hoste, Lock, & Le Grange, 2010), (2) cognitive behavioral
therapy (see Dalle Grave, Calugi, Doll, & Fairburn, 2013),
(3) cognitive remediation therapy (see Lask & Roberts,
2013), and (4) emotion focused family therapy (see Robinson,
Dolhanty, & Greenberg, 2013).
There is a need for clinicians to have a variety of treatment
intervention options when working with families with a child
diagnosed with an eating disorder. However, to have a breadth
of training and knowledge in the various modalities can be
costly for agencies. It can also be confusing to clinicians in
selecting which treatment to implement when there is a non-
response to family-based therapy. Clinicians can also struggle
with how to effectively change and manoeuvre between these
treatments. As a result, the pressure clinicians may place on
parents to adhere to the family-based therapy treatment recom-
mendations may increase frustrations and a sense of hopeless-
ness when the model is proving to be noneffective. Switching
to another treatment can be confusing to parents and may send
mixed or contrasting messages if the course of treatment differs
greatly from family-based therapy.
Many of these alternative treatments do contradict family-
based therapy and focus on the adolescent as an individual. The
parent role is seen as secondary, perhaps having only once-a-
month progress sessions or 15 min at the end of a session for
support. This puts parents in a confusing position of going from
the prime role in the recovery to taking a back seat and becom-
ing a supportive bystander.
There are no clear protocols as to how to end family-based
therapy and transition to alternative treatment, but generally
treatment termination is based upon agency/institutional agree-
ment. Thus, it is recommended that at the outset of family-
based therapy treatment, the explicit limits of the program be
communicated to parents. Should there be an “inability on part
of the family to mobilize weight gain,” it may be beneficial for
teams to meet with parents to discuss progress and to reevaluate
the fit of family-based therapy for the patient and family
(Woodside, Halpert, & Dimitropoulos, 2015, p. 368).
Exemplar. Justin was a 16-year-old male who frequently
exercised to burn calories and restricted his caloric intake,
although his weight loss had not yet put him in the diagnostic
criteria for anorexia nervosa. Family-based therapy was imple-
mented for about six sessions, or a month and a half, but his
weight loss continued. After a lengthy discussion during clin-
ical rounds and with Justin’s parents, it was decided that Justin
would try adolescent focused psychotherapy. Justin’s parents
found this helpful and less stressful as sessions were individual
for Justin and collateral sessions for parents were infrequent.
However, over time, Justin’s parents began to struggle with
their lack of knowledge about what Justin was saying in ses-
sions as well as how to deal with Justin continuing to make his
own meals separate from the family. This, in fact, led to con-
flict as his parents would attempt to try to implement aspects of
family-based therapy despite no longer following this treat-
ment model. Justin’s parents struggled to be supportive of Jus-
tin’s “self-directed change” (Fitzpatrick et al., 2010, p. 35).
They felt they could not watch their child struggle in front of
them while they did, in their words, “nothing,” especially after
recalling the importance of parental involvement in family-
based therapy treatment.
Family-Based Therapy Expectations
of Parents
Research on adolescent interventions for eating disorders
recognizes that the involvement of parents in treatment
improves the chances of recovery (Godart et al., 2012). Parents
are no longer considered to be part of the cause of eating dis-
orders, instead they are seen as part of the solution. However,
Scarborough 93
family-based therapy can place high demands on already
exhausted parents and the pressure to implement the treatment
and monitor their child may prove to be daunting. There is a
responsibility and pressure for parents to follow the recom-
mended treatment, regardless of how taxing it may be, and
failure may be seen as caused by the parents’ inability to carry
out the treatment. In addition to caring for their ill child, parents
face external pressures when engaging in treatment.
Time and Finances
In family-based therapy, the expectation is that the entire family
will attend treatment sessions. For parents, this may mean tak-
ing time off work every week (Plath, Williams, & Wood, 2016).
A study of caregivers with a loved one above the age of 18
diagnosed with an eating disorder found that 40% of caregivers
reported having high (>21 hr per week) face-to-face contact
with their child, most of which was spent giving emotional and
nutritional support (Raenker et al., 2013). Given the recom-
mended family-based therapy model, it can be assumed that the
time demands on caregivers of an adolescent include signifi-
cantly higher face-to-face contact and support with their child.
This leaves little time for parental self-care and preservation as
well as time for other children or other aspects of living.
In family-based therapy, parents are expected to take charge
of their child’s weight restoration and interruption of symptoms
(i.e., exercising, vomiting, and restricting). Parents are often
spending more time preparing meals, waiting hours over these
meals for their child to finish, and monitoring their child if there
is compulsive exercise or other harmful behaviors (Findlay
et al., 2010). A recent study by Månsson, Parling, and Swenne
(2016) identified that parent directive tasks for family-based
therapy include having the child stay home from school, having
all meals with a parent, and not allowing the child to exercise or
vomit. While parents who could implement these tasks had
children who gained weight more quickly, the time required
to do these tasks, coupled with the emotional turmoil that par-
ents experience while intervening, is significant.
If parents are to intervene and effectively interrupt eating
disorder symptoms, it may be required that the child be
removed from school and a parent take a leave of absence from
employment (Hillege, Beale, & McMaster, 2006). The finances
lost by taking time off work, gas mileage, and parking, com-
bined with (for some parents) needing to buy additional high
energy items (i.e., homogenized milk, boost-plus drink, and
high-calorie granola bars) can create added stress on parents
during an already challenging time. Single parent families may
need a longer duration in family-based therapy treatment,
meaning a longer duration spent in financial strain with only
one income (Lock, Agras, Bryson, & Kraemer, 2005).
ExemplarMegan was a 14 year old with a diagnosis of anor-
exia nervosa purging subtype. She had purging symptoms via
vomiting and excessive exercising. Her family consisted of her
father who worked as a car mechanic, her mother (Susan) who
worked at a grocery store, and two siblings aged 16 and 12.
Given the severity of Megan’s difficulties, Susan took a leave
of absence from work to be able to prepare all her meals and
provide supervision postmeals. Megan was also removed from
school at the beginning of treatment while her parents
attempted to refeed her.
During a session, Susan was tearful when explaining that
because she was not working, their family budget could not
accommodate soccer for her other two children. The siblings
were reportedly very angry and blamed Megan. The agency
was able to provide funding for the two children to attend
soccer; however, Susan stated that she was not sure whether
she or her husband had the energy or time to drive each child to
their soccer games while also being present for
Megan.
Megan’s dinner would often take several hours to complete,
going well into the time when soccer would begin. When dis-
cussing if other parents of the soccer team members would be
able to bring the children to games, or if their father could take
over a meal role, Susan explained feeling guilty that all her
time and her husband’s was spent on Megan and that the other
two children were feeling neglected.
In the end, the siblings did not enrol in soccer. The siblings
were encouraged to continue to attend family-based therapy in
order to express their own frustrations and have their voices
heard; however, they often stated that they did not wish to
attend as they had other activities and homework they would
rather spend their time on than go to therapy.
Relationships
It is well-documented that eating disorders create tension and
challenges in family relationships (Gilbert, Shaw, & Notar,
2000; Highet, Thompson, & King, 2005; Hillege et al., 2006;
Honey & Halse, 2006). The demand family-based therapy has
on parents is exacerbated by potentially neglected relationships
with other family members. Maintaining relationships with
family members and friends is overshadowed by the reality
of the illness as well as the family-based therapy treatment and
its requirements. In family-based therapy, the whole family,
including siblings, are required to attend treatment, and family
vacations are often cancelled while the eating disorder beha-
viors are addressed and weight is restored (Gilbert et al., 2000).
These changes that affect the whole family can lead to resent-
ment, particularly between siblings, which adds another stres-
sor that parents need to manage.
Parents living together report that stress and strain increases
in their marriage (Hillege et al., 2006). This is a particularly
impactful reality of treatment, given that successful family-
based therapy requires parental unity and consistency. The
maintenance of the marital relationship and effective commu-
nication is crucial for successful treatment, yet time spent on
the couple relationship becomes less frequent. Parents are
under pressure to focus on creating consistent parenting proce-
dures and supervision of the child with an eating disorder.
Parents also report isolation from others (Treasure et al.,
2001). While relationships outside the home may offer addi-
tional support and respite for parents, making time for outside
relationships is difficult. In addition, parents report that many
94 The Family Journal: Counseling and Therapy for Couples and Families 26(1)
outside individuals, including extended family members, do
not completely understand the illness, and feeling stigmatized
from community members is well-documented (Ebneter, Lat-
ner, & O’Brien, 2011; Griffiths, Mond, Murray, & Touyz,
2015; Mond, Robertson-Smith, & Vetere, 2006; Stewart, Keel,
& Schiavo, 2006; Stewart, Schiavo, Herzog, & Franko, 2008).
This may be particularly difficult for single parent families who
are tasked with refeeding without support from an immediate
partner.
ExemplarIn the case of Megan’s family, there were many
reports of relationship difficulties and struggles beyond the
siblings’ resentment of Megan and the time and attention she
received from her parents. Susan (Megan’s mother) often felt
that she was alone in the refeeding, despite her husband being
available at breakfast and dinners as well as on weekends.
Susan spoke of how her husband was the sole income earner
and was unable to wait for Megan to complete her breakfast as
time spent waiting for her meal to finished would make him
late for work. At dinnertime, Susan’s husband was often
exhausted from his job as a mechanic and would become short
and angry with Megan when she would not comply with her
meal. Susan felt this caused more stress in the family and in
their marital relationship.
When discussing how to create time to connect with her
husband, Susan struggled. Even in the evenings, it was difficult
to connect as Susan was sleeping in her daughter’s room
because Megan would exercise in the middle of the night.
Planning couple evenings out was also a struggle. Extended
family lived out of province and Susan’s friends really did not
understand the seriousness of the illness and how to support
Megan.
Susan continued in isolation refeeding her daughter with
great difficulty. The therapist recommended that Susan call the
agency and speak with a clinician when she was struggling,
feeling isolated, or just needed to vent. Often, after hours,
Susan would leave voice messages explaining the difficulties
she had that day.
Megan did regain weight to a healthy range and later ses-
sions were focused on repairing relationships within the family
with the clinician using emotion focused family therapy tech-
niques. This required additional sessions beyond those outlined
in manualized family-based therapy.
Parenting Adjustment and Eating Disorder Resistance
Family-based therapy requires that parents monitor all meals
for the ill child in order to achieve weight gain. For many
parents, this poses a challenge since adolescence is generally
a time of autonomous exploration, yet treatment requires that
parents put autonomy development on hold for their child’s
health. Parents have to learn a new way to discipline and raise
their adolescent. For some parents, the struggle is how to parent
a child whom they no longer recognize. For example, Treasure
et al. (2001) noted how an introverted and worrisome child had
turned into having a volatile personality with “violent mood
swings” (p. 345).
Many parents find it difficult to differentiate what is normal
adolescent behavior and what is distress caused by the eating
disorder. For this reason, parents struggle to determine how to
discipline their child’s (at times) violent or abusive reactions
(Honey & Halse, 2005). Due to these reactions, parents may not
challenge or set boundaries for their child’s behaviors and are
often described as walking on eggshells around the adolescent
(Gilbert et al., 2000; Highet et al., 2005). Siegel (2010) noted
that when parents experience intense emotions, such as fear,
they may lose their innate caregiving knowledge. For example,
the fear of reintroducing a challenging food item that may
result in severe distress in their child may lead a parent not
to introduce the food at all (Stillar et al., 2016). For parents, the
pressure to push their child to eat resisted foods, or a higher
volume of food, may prove to be too difficult and produce fear
in parents. In family-based therapy where parents are to func-
tion as nursing staff, it is almost impossible for them to do so
without becoming emotional. In fact, this is what makes the
task challenging. It can be particularly hard for parents to
remain focused on refeeding when their child is threatening
self-harm or suicide.
Eating disorder treatment can also be a lengthy process
lasting from 6 to 12 months. Parents are faced with the strug-
gles of mealtimes, often 6 times a day, that are frequently
accompanied by distressing behavioral and mood changes. Par-
ents are the target of the child’s verbal and at times physical
backlash (Treasure, 2010). Kyriacou, Treasure, and Schmidt
(2008) found that comorbid behaviors combined with the
child’s rejection of help contribute to caregiver strains.
A study by Coomber and King (2013) found individuals
with an eating disorder underestimate the level of burden that
their loved ones experience. While for other illnesses, parents
may receive some response of appreciation for the sacrifices
they have made, in the case of eating disorders this is often not
the norm. This consistent lack of appreciation from the child,
and in fact more of a negative response to parental efforts,
contributes to parents doubting their role in their child’s treat-
ment. This leads to a greater chance of disillusionment with the
recommended treatment and a higher risk of burnout.
ExemplarLeona was a 13-year-old female diagnosed with
anorexia nervosa. Her parents described her as a child
that never yelled and never needed to be disciplined.
However, once the family began family-based therapy,
Leona became extremely violent, hitting her head on the
table and screaming at her parents during mealtimes. Leo-
na’s parents struggled to discipline her. They were unsure
whether disciplining Leona would be viewed as punish-
ing her for a symptom she could not control. Leona’s
parents continued to ignore the violent outbursts, but
when she began to threaten suicide, her parents stated
they could not continue to push her to eat high-calorie
meals. Despite Leona admitting to the clinician that she
was not suicidal and it was a desperate emotional reac-
tion, her parents began to collaborate with Leona around
mealtimes in order to prevent the hostile environment at
Scarborough 95
the dinner table. This collaboration led to continuous
weight loss as Leona took control of her meals, knowing
that her parents were fearful of challenging her.
Discussion
Although family-based therapy is a promising treatment for
adolescents diagnosed with an eating disorder, many factors
still need to be explored in terms of clinician barriers and
parental challenges that make this treatment difficult to imple-
ment. As stated by Rhodes, Baillie, Brown, and Madden
(2005), “given the establishment of the efficacy of the
[Family-Based Therapy], there is now a need for researchers
to turn their efforts to the question of how it can be improved”
(p. 400). By acknowledging these potential difficulties,
researchers and clinicians can create better supports for parents
in the treatment process.
The feasibility of resolving the barriers discussed in this
article is challenging. Additional finances for agencies are dif-
ficult to come by which affects proper training and supervision
for family-based therapy clinicians. For parents, a major issue
is what they can realistically give up without creating excessive
financial hardship. Agencies could potentially implement alter-
native session hours that are more in line with parent work
hours, but this requires agency staff to adjust their personal
lives and family responsibilities.
It would be useful for clinicians to frankly discuss with par-
ents the realities of life while in treatment and what they may
have to give up. As parental motivation is necessary for family-
based therapy, it is of importance to explore with parents what
could be demotivating to adopting this therapy model. Clini-
cians need to acknowledge the pressures and challenges that
parents will face in family-based therapy and have a clear dis-
cussion with parents on how to best support them through these
challenges. Making this a mandatory part of the initial clinical
assessment could be useful in starting the dialogue about chal-
lenges and how to problem solve issues as they arise. It may also
be beneficial for researchers to focus on how clinicians can
discuss these challenges with parents without shame or blame
and while maintaining hopefulness in the treatment.
Clinicians would benefit from supervision during family-
based therapy practice to uncover the ways in which their own
anxieties and judgments may impede them from implementing
the treatment. Supervision may also help with the transitioning
between treatments should there be a nonresponse to family-
based therapy. Agencies may benefit from implementing clin-
ical rounds that are focused specifically on the difficulties with
implementing family-based therapy, discussing specific cases
and problem-solving around these identified barriers. This
would help clinicians to remain true to the manualized model
of family-based therapy and to discuss key aspects of family-
based therapy that they struggle to implement rather than sim-
ply not applying the recommended tasks. This is also a more
cost-effective way to provide supervision.
The impact of the financial, relational, and emotional pres-
sures on parents is important for future research to explore. It is
also important to examine how parental experiences affect the
implementation of family-based therapy and long-term results.
By doing so, the field can better understand the challenges
parents face and how improvements could be made in order
to prevent dropout, parental burnout, and helping to combat the
potential chronicity of the illness.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, author
ship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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Contents lists available at ScienceDirect
Aggression and Violent Behavior
journal homepage: www.elsevier.com/locate/aggviobeh
Looking for the origins of anorexia nervosa in adolescence – A new treatment
approach
S. Matt Lacoste1
Univeristy of Toulouse, 5 Allée Antonio Machado, 31000 Toulouse, France
A R T I C L E I N F O
Keywords:
Anorexia nervosa
Family
Sexual assault
Psychological treatment
Case study
A B S T R A C T
Anorexia nervosa is an eating disorder, which affects particularly adolescents. The media coverage of feminine
thinness is demonstrated as a token of beauty, with diet as a tool to achieve this. However, diets are not enough
to explain the numerous cases. This disease is the symptom of a psychological disorder and looking for the origin
must coincide with psychotherapeutic treatment. Multifactorial explanations seem dominate within our female
patients. For most female patients, family problems and past experience with sexual assault explain this tran-
sition to anorexia. It is demonstrated throughout this paper how and why anorexia nervosa is used as a tool for
identification and personalization in the assumption of autonomy and independence, and how and why anorexia
becomes a defensive response to aggression. We give a clinical confirmation of the diverse origins of anorexia
nervosa and of the impact of sexual abuse. This paper proposes a new therapeutic approach to patients with
anorexia nervosa, in which the eating disorder is a symptom of an emotional disorder, often triggered by sexual
assault or emotional deprivation.
1. Introduction
Anorexia Nervosa is an “eating disorder with more or less system-
atized refusal to eat, acting as a reply form to psychic conflicts”
(Bloch & al., 2000). People with anorexia nervosa (90% are women)
have a distorted body image that causes them to see themselves as
overweight even if they are dangerously thin. In their lifetime2 0.5% to
3.7% of females suffer from anorexia nervosa. It is the third most
common chronic illness among adolescents3 after obesity and asthma.
Populations most deeply impacted by anorexia nervosa include women
in the age ranges 13–14 years old and the 18–20 years old. Studies
continue to support this research, noting that 95% of those who have
eating disorders are between ages of 12 and 25.4 Anorexia nervosa is a
full disease which impact around 1.5% of French women of 15 to
35 years old. Additionally in the United States of America, studies es-
timate that 1% of adolescents and 0.5 to 3.7% of women suffer from
anorexia nervosa.
While women of all social classes are impacted from anorexia ner-
vosa, it can be noted that matriarchal families seem to be over re-
presented (Marcelli & Braconnier, 2004). These subjects tend to deny
that their eating behavior is problematic and we estimate that only one
third of these people have received a treatment. Of these 30%, the
percentage of people recovered completely is low (Herzog,
Nussbaum, & Marmor, 1996). Four years after the anorexic period we
count 44% of patients with good recovery, but seven and half years
after, this number decreases to 33% (Herzog et al., 1999). A majority of
studies find that only 11% to 40% find recovery and 1 out of 2 anorexia
nervosa subjects relapse.
In accordance with Botha’s (2012) observations, traditional under-
standings and approaches to diagnosis and treatment for anorexia
nervosa seem to be unacceptable, inappropriate and laden with social
stigmatism. Societal stigma exacerbates these patients’ struggles,
leaving them dishonored, disabled, powerless and possibly in a place of
greater distress.
These factors in mind, as psychologist who treats anorexia nervosa
subjects, there are many questions that elevate in regards to recovery,
treatment, and long-term success for these individuals. The family
problematic and sexual abuse seem to be the mains origins of the be-
ginning of anorexia nervosa. The main idea is to understand the link
between the origin(s) of the disorder and its implementation. In this
way, a therapeutic strategy appears.
Understanding the inner thoughts of these individuals is essential in
http://dx.doi.org/10.1016/j.avb.2017.07.006
Received 28 October 2016; Received in revised form 13 June 2017; Accepted 26 July 2017
1 Psychologist (Private Practice) – Assistant Professor of Psychology.
E-mail address: Dr.matt.lacoste@gmail.com.
2 National Institute of Mental Health (1994).
3 Public Health Service’s Office in Women’s Health – Eating Disorders information Sheet (2000).
4 Substance Abuse and Mental Health Services Administration – US Department of Health and Human Services.
Aggression and Violent Behavior 36 (2017) 76–
80
Available online 03 August 2017
1359-1
78
9/ © 2017 Elsevier Ltd. All rights reserved.
MARK
http://www.sciencedirect.com/science/journal/13591789
http://www.elsevier.com/locate/aggviobeh
http://dx.doi.org/10.1016/j.avb.2017.07.006
http://dx.doi.org/10.1016/j.avb.2017.07.006
mailto:Dr.matt.lacoste@gmail.com
http://dx.doi.org/10.1016/j.avb.2017.07.006
http://crossmark.crossref.org/dialog/?doi=10.1016/j.avb.2017.07.006&domain=pdf
understanding why the recovery for this population is so challenging
and why treatments are mostly ineffective. With a bottom-up clinical
analysis of four patient therapies, throughout this paper we hope to
answer to these questions.
2. Literature review
1- Adolescence and family: a family issue as anorexia nervosa origin.
Anorexia Nervosa and Bulimia are linked to multiples factors
usually associated with psychological, family, social and biological in-
fluences. These items intertwine and impact each over, contributing to
the initiation, the maintenance and to the exacerbation of eating dis-
orders (Rogé & Chabrol, 2007). Coinciding with this notion, Fairburn
and Harrison (2003) found a combination of genetic variables im-
plicated anorexia nervosa development in conjunction with environ-
mental implications. Friends and family circle are connected to the
disorder de facto, by the causes, by the consequences or both. We could
find three times more anorexia nervosa subjects in the families whose
parents have a history of this disorder (Strober, Morrel, Burroughs,
Salkin, & Jacobs, 1985). This could confirm the genetic dimension of
eating disorders displaying during the 1990s’ (Bulik, Sullivan,
Wade, & al., 2000; Grice, Halmi, Fichter, & al., 2002). But, the herit-
ability of liability to eating disorders as Bulimia nervosa is difficult to
prove (Fairburn, Cowen, & Harrison, 1999). For Collier and Treasure
(2004, p. 365), “Increasingly, the consensus is that eating disorders are
complex disorders consisting of both genetic and social factors, with a
developmental component strongly linked to adult illness”.
Even if it seems difficult to define a psychological profile of anorexic
adolescents’ parents, studies show that anorexia nervosa is more
common with distant parents who would be inclined to neglect their
child, to not show affection, and when communication with children is
volatile. Conversely, it is also found within families with overprotective
parents who would be possessive, pervasive and they encourage ex-
cessively the family cohesion. These parents’ behaviors are typical of
the parents of anorexic child. “Many authors (Brusset, 1998; Jeammet,
1993) focus on failures in primary identification process mother/
daughter marked with a dependency where the ambivalence dom-
inates. The nature of the primary links would explain the frequent
narcissistic breaches in these patients, and breaches are responsible of
wrong perceptions of self-image and of body” (Marcelli & Braconnier,
2004, p. 153).
Shoebridge and Gowers (2000) found that the mothers of anorexia
nervosa subjects reported higher rates of near-exclusive child care, se-
vere distress at first regular separation and high maternal trait anxiety
levels than the mothers of control subjects. They also showed that fa-
milies with anorexia nervosa case, had experienced a severe obstetric
loss prior to their daughter’s birth. This could confirm that over-
protecting parents or high concern parenting in infancy could be as-
sociated with the later development of anorexia nervosa.
If the earlier mother’s behaviors would have a negative impact on
the adolescents’ eating behaviors, anorexia nervosa could be considered
as bodily intersubjective. The eating behavior and transformation of the
subject’s body play a role in the family relationship. Anorexia nervosa
affects not only the subject’s relation to food but also her relation to
others (Legrand & Briend, 2015) and especially to her parents. The
anorexia nervosa subject would use as a tool her eating disorder and
bodily shape to address others, to manifest her distress or her desire, to
put the others, and specially the parents, in a position to answer or to do
something for her distress (Legrand & Briend, 2015). The study of
Rothschild-Yakar, Levy-Shiff, Fridman-Balaban, Gur, and Stein (2010)
indicated that anorexia nervosa type patients presented significantly
lower mentalization levels and lower quality of current relationships
with their parents compared with non-eating disorder controls. When
the verbal dialog seems to be difficult, the adolescent would choose
another communication tool. Additionally, the adolescent could also try
to take power from her parents by her eating behavior. Indeed, anorexia
nervosa subjects are obviously facing with paradoxical behaviors and
thinking. The adolescent who searches for more autonomy, claims with
conflict more independence, addresses to her parents to be taken care of
by her eating disorder.
If sometimes, adolescents use anorexia nervosa to say something
because it’s too hard to use words, the therapy is the time to speak about
their distress. Several researches found a link between sexual abuse or
rape and anorexia nervosa.
2- Anorexia nervosa and sexual abuse.
Even if it is always difficult to have accurate measure of sexual
abuse rates, as confirm Fallon, Collin-Vezina, King, and Joh-Carnella
(2017) international trends from recent meta-analysis has shown
alarming rates of sexual abuse cases with 18 to 20% for females
(Pereda, Guilera, Forns, & Gòmez-Benito, 2009). Additionally, we know
that 70 to 75% of child victims wait 5 years or more to report before
disclosing the abuse (Hébert, Tourigny, Cyr, McDuff, & Joly, 2009). The
interaction of different factors, with some can be unconscious and dif-
ficult to identify, are generally at the origin of anorexia nervosa. Even if
it is sometimes possible to isolate a trigger event (e.g. injuring comment
on physical appearance, fight with parents, divorce of parents, romantic
break-up); it is typically one event too many more rather than an iso-
lated explanation. By contrast, it would seem that sexual assaults can be
the (main) explanatory trigger of anorexia nervosa. Even if some re-
searches try to argue the link between sexual abuse and eating disorders
(e.g. Smolak & Murnen, 2002), several studies confirm the results in our
patients in private practice. Favaro, Tenconi, and Santonastaso (2010)
show that physical or sexual abuse of children result significantly in
anorexia nervosa during adolescence. Deep, Lilenfeld, Plotnicov,
Pollice, and Kaye (1999) found that 27% of anorexia nervosa subjects
had antecedent of sexual abuse compared to a rate of 7% in control
women subjects and it could be more important for bulimia nervosa
patients (Casper & Lyubomirsky, 1997). According to the Center of
Disease Control and Prevention (2007), 1 in 4 of young people ex-
perienced verbal, physical emotional or sexual abuse from a dating
partner; 8% have been forced to have sexual intercourse when they did
not want and nearly 10% were hit, slapped or physically hurt by a
boyfriend or girlfriend within the 12 months prior taking the survey.5
Sexual abuse has been reported to occur in 30% to 65% of women with
eating disorder compared to 10% to 30% in rates of sexual abuse in the
general population (Connors & Morse, 1993; Daigneault, Collin-
Vézina, & Hébert, 2012; Deep et al., 1999; Zerbe, 1992). Faravelli,
Giugni, Salvatori, and Ricca (2004) shown that 53% of rape victims
reported current eating disorders symptoms compared to 6% of control
subjects. Thompson and Wonderlich (2004) found the same results.
Fischer, Stojek and Hartzell (2010, p.192) specify that a childhood
emotional abuse can be a predictor of current disorders symptoms.
They explain this result by the hypothesis “that an emotionally abusive
environment does not teach adaptive emotion regulation skills, and that
the use of maladaptive emotion regulation skills results in eating dis-
orders symptoms”. The eating disorder can be a strategy of avoidance or
regulation of emotion. Lejonclou, Nilsson, and Holmqvist (2014) con-
firm that for several traumas, the eating disorders subjects had ex-
perienced a significantly larger number of potentially traumatizing
events, and they specify that the number of adverse childhood experi-
ences and repeated traumas were associated with eating disorders for
adolescents and young women. All kind of child sexual abuse is a
traumatic experience and one of the major risk factor in the develop-
ment of mental health problems affecting both the current and future of
victims (Collin-Vézina, Daigneault, & Hébert, 2013).
Lyubomirsky, Sousa, and Casper (2001) specify that some
5 CDCP – Youth Risk Behavior Survey (2007).
S. Matt Lacoste Aggression and Violent Behavior 36 (2017) 76–80
77
personality traits like dissociation can mediate the relationships be-
tween abnormal eating and sexual abuse. The women with functional
coping could avoid binge eating even in case of sexual abuse, inversely
the dissociation associated to others negative affects lead to the most
important eating disorders.
In our non-exhaustive literature review, family and sexual abuse
seem to be two important origins of a disordered eating behavior and
can be associated in the development of the disorder. What about our
patients? Do they confirm these explanations? And how we can clini-
cally explain these processes?
3. Method
This article draws a new approach in the anorexia nervosa treat-
ment and in patient monitoring. Through a case study, the main goal of
this paper is to wonder about the origin of anorexia nervosa as well as
the adolescence specificity linked to these eating disorders.
This paper mainly uses 4 outpatient cases that were treated with
success in our private practice as clinical psychologist. We have selected
these cases to cover different ages and histories of the anorexia nervosa,
and because these women explained with their own words how and
why the anorexia nervosa became for them an answer, a coping
strategy. They also well represented the majority (67%) of our patients.
Mrs. C. (48 years old) suffered with anorexic eating behavior since
childhood. Raped at 22 years old, this assault intensified or escalated
the eating disorders. The therapy will reveal parents’ sexual and emo-
tional abuse since a young age. Now, she’s married, mother, and she’s a
female entrepreneur who put a lot of time and energy in her job.
Ms. E. (25 years old) was in her 4th year of graduate studies but
struggling a burn-out about her studies. The anorexia nervosa began
7 years before, she was an inpatient facility to address this crisis and her
endangered health. The numerous inpatient weeks did not give sa-
tisfactory outcomes. The relapses were systematic. She came the first
time with her mother who spoke more than Ms. E. about her health and
about the importance of her studies and graduation in 16 months.
Ms. D. is 17 years old, bright teenager with good results at school.
She was living with the anorexia nervosa for almost two years. She has
an older sister (24 years old) who is married and recent mother of tri-
plets. Ms. D.’s parents consider her older sister to be a role model and
often compare them. Ms. D. lived with her parents. They were over-
protective but since the triplets were born, they only focused on the
“new babies”.
Ms. S. (16 years old) develops an anorexia nervosa 2 years ago. Ms.
S. has to regularly help her mother to prepare family meals. During the
psychotherapy, Ms. S. will reveal she was raped at 14 years old by one
of her classmates, who is also a neighbor.
4. Data analysis and discussion
We introduce a case study of four female patients voluntarily en-
gaged in a therapeutic process. The therapeutic monitoring was orga-
nized with one or two weekly therapeutic consultation outpatient ses-
sions. The patients were fully with the disease or in the latter stages of
recovery, and their comments collected will be confronted with our
literature review and discussed.
1- Adolescence and family in our cases.
This is a fact that cultural and media pressures to be thin contribute
particularly to increase the number of eating disorders subjects (Fallon,
Katzman, & Wooley, 1994). This explanation is confirmed by Ms. E.
(25 years) when she explains “I felt round, I was 117 pounds for 5.2 feet,
so I went on a diet and gradually I could not swallow anything and I fell to
81.5 pounds”. But going further in our conversations, the family issue
came to emerge in the explanation of the disorder origin: “When I eat, I
feel fat and guilty because it costs money to my parents. […] Today I’m
desperately ill, I do not want to fight anymore. I have enough of life espe-
cially when I see that I hurt my parents”. A normal diet is often a mask
developed by the person to hide from the others (and from oneself
sometimes) the anorexia nervosa process which is going on. Anorexia
nervosa is addressed to others, inviting or rejecting them. Ms. E. seems
to manifest an alimentary communication by stripping food from its
nutritional matter in order to make it of an element of language, Ms. E.
would materialize her hunger in her body which is transformed to
address it to her parents (Legrand & Taramasco, 2016). These authors
explain that the subject eat, she eat nothing. This “nothing” she eats has
not gotten a nutritional value but a symbolic one. The food or the meal
is a communication system, and in this way anorexia nervosa is a food
communication. When she eats nothing, the anorexic subject removes
the nutritious matter of food to keep the language part only.
Conflicts are numerous during adolescence, they come from parents,
family, friends, loves, teachers, studies. They can be internal to the
subject herself who does not accept her body and the transformations
related to adolescence. Body changes are sometimes marked during
puberty and girls can, by anorexia nervosa, attempt to regain power
over this body that no longer suits them and no longer meets their
expectations.
Ms. E. (25 years) put her anxiety into words for others to under-
stand, “I don’t like when there are people at home and this is worsened if it
was not planned. At others’ home it’s just bearable. The more people that are
there, the more I fear”. But this distinction between home (family home)
and among friends does show us an underlying family problem ex-
plaining the disorder and the discontent facing this other? She fears this
invader who is going to introduce himself into her family cocoon plus to
observe and to note her thinness. Maybe, these “foreign family people”
could endanger her attempt to take the power on her parents. Anorexia
nervosa subjects can maintain the disordered eating behavior and their
thinness to preserve the family circle or the family unit (Selvini-
Palazzoli, 1986) because anorexia nervosa creates a reason to be
helpful, to be together.
The children or the teenager can use anorexia nervosa to avoid
growing up. By remaining a child, the person retains the carelessness of
childhood and keeps the parenting focus. Like that, Ms. E. (25 years)
confides, “I live at my parents’ home, they shake me all the time. They are
unhappy, my father is often angry. I feel guilty. They often tell me “you are
almost an adult, it’s time you took responsibility for your actions!”.
Becoming an adult is often perceived as a loss, as a nightmare to face
problems, constraints, obligations of life; it’s becoming responsible for
yourself (and others). “Eat your soup, you will grow up” can take some
teenagers into major anxiety. By not eating, could it not represent for
these children the symbolism of the fetal period when the umbilical
cord ensured that role for them?
Ms. D. (17 years) explained this, “my sister had just had triplets, I
struggled with that. Until that time I was the youngest of the family and I
used to get all attention. Suddenly all the attention focused on them and the
only thing I had left was my diet. And every time I felt alone, I consoled
myself by losing a pound. […] Finally, they paid attention to me, they
started to take care of me, they did not leave me alone anymore. […] This is
a part of me, I would like to stop, I don’t want to die but it’s very hard and I
don’t know how I can do it.” Ms. D. was also fighting against this am-
bivalence of adolescence. This constant quest of other people’s look,
express what the anorexia subject wants more than anything but what
she cannot say Take care of me! (Jeammet, 2010). Ms. S. (16 years) can
blame too sustained attention of her mother and at the same time she
maintains this concern by her eating behavior, “My mother always
bothers me so that I eat, she bugs me! Eating, this is not fun, it became an
order”. Therefore, her anorexia nervosa would become an opposition to
her mother to access some independence, typical of adolescence. At the
same time, her eating behavior is a tool to maintain her mother role like
nurturing, and to see her as a child. Thus, anorexia nervosa is the
“perfect” strategy which answers in the same time to two opposite
goals, and answers to the internal conflict of adolescence (not more a
S. Matt Lacoste Aggression and Violent Behavior 36 (2017) 76–80
78
child, not yet an adult).
This is another example of the paradoxical relationship between the
anorexic subject and others. The social (parental) relationships are
frightening and necessary in the same time, frightening because ne-
cessary (Jeammet, 2010). This ambivalence often appears with Ms. S. as
well when she describes herself. Our one on one allowed her to express
the limits of her behavior, and help to move beyond her disorder, “I feel
that there is a combination of two girls in me: one very ugly and one very
beautiful. I think I’m fat and thin […] I would like to be perfect to please
myself but I consider myself too thin now and I’m afraid to go to the beach”.
Ms. S. confirms here that her fine body bears the traces of her internal
trouble and in the same time, her obvious thinness express her un-
iqueness in the space where others can see these traces and respond
(Legrand & Taramasco, 2016). Relationships with parents are often re-
lationships of dependence. However, anorexia nervosa of the teenager
tries to reverse the roles because family becomes dependent of the
adolescent and of her relation to the food. This hold ensures the success
of an illusory control of the affective and family sphere. Conflicts with
parents become inevitable which reinforce the anorexia behavior. For
Legrand and Briend (2015) anorexia nervosa subjects struggle with this
paradoxical behavior because they fail to negotiate the difference be-
tween needs and desires. Desires are often insatiable and whether the
parents satisfy the needs, they cannot fulfill the unfulfillable desire.
For that matter, Ms. E. (25 years) confided that her “cousin is doing
the same, we were brought together. My mother’s side is considered quite
beefy. My aunt, my uncle, my grandfather are overweight. For my uncle, it’s
the same, he was an anorexic subject”. Did Ms. E. confirm a genetic role in
the explanation of the anorexia nervosa or did she describe a family
who cultivate an environment which fosters the development of anor-
exia nervosa? Was she fighting against a family relationship because
she felt a subjugation of her subjectiveness? That fear can be a reject of
the other, or a call to the other, or both together (Legrand & Taramasco,
2016).
The eating disordered behaviors often lead to a hostage of the fa-
mily which is undergoing a major anxiety regenerated at each meal-
time. The circle, particularly parents, tend to act and behave according
to the wishes and moods of the adolescent hoping she’s going to nourish
herself. Thereby if a balance of power can be built, the adolescent takes
the power on the destabilized and distressed parents, by submitting this
disorder living in a permanent anxiety about each possible future de-
viant. By playing on the feeling of guilt and on the protective parent-
hood sprout, the anorexic subject undermines the identity of parents
and put their social positioning and their attitudes in doubt. Indeed, at
the end of the therapy, Ms. D.’s mother said, “I do not think that we could
turn the page. There will always be this pall hanging over us at least as long
as she lives at home. We will have a little anxiety to know if she’s eating all
her meals. Me, I will wonder this, anyway”.
After analysis, Mrs. C. (48 years) also verbalized that she ate during
her childhood and adolescence at the level of the perceived parental
love. Developing a sense of abandonment, of lack of affection and of
reject from her parents, she expressed her feeling of these perceived
deficiencies, in the eating deficiencies. She experienced a correspon-
dence between the misery intensity and the anorexia nervosa. Mrs. C.
cumulated a harmful family environment, sexual abuse and rape.
2- Anorexia nervosa and sexual abuse in our cases.
Our practice confirms a large rate of young girls or women with
anorexia nervosa symptoms who were sexual abuse or rape victims
(67% of our anorexia nervosa patients). Cannot this physical attack, still
in that whole power of the mind over the body, expresses itself as well
in these young girls who have suffered sexual assaults? Because of the
bodily damage and the stolen privacy, it seems logical that the lack of
interest for sexuality is described as a symptom of anorexia nervosa.
Even if the sexual abuse and rape victims are not suffering of eating
disorder, within our cases, sexual assault can be cause of anorexia
nervosa and the weight loss. Ms. S. (16 years) explained that she fell in
anorexia nervosa after she was victim of rape. She said anything to
anybody before her psychotherapy, “after the rape by my neighbor, I felt
dirty, ashamed and guiltier than victim. I did not like the life anymore, I no
longer felt hungry, I did not want to do anything. But I kept the secret and
live like a robot, a scared robot”. The rape was clearly the triggering
event, but Ms. S. connected the family problematic when she said “In
addition, my mother always wants me to help her to prepare meals, I hate
that, it makes me even more disgusted”. With the secret of the rape wrote
on her body but invisible for the other and with a specific problematic
about food in her family, Ms. S. seemed to use the anorexia nervosa to
express her pain and to reveal her secret in order to wean herself off it.
The conflicts with her parents became regular, but it was a paradoxical
rebellion, remained under the wraps at the beginning, the secret
wanted to be visible to all by her gaunt body. Again, we understand
how anorexia nervosa is communication, it is a patient and stubborn
building of a body of which his vulnerability is a cry for protection
(Legrand & Taramasco, 2016).
The desexualization that results would have the goal to protect the
young girl who hopes with that she’s not going to create the desire of a
man anymore. Kestemberg, Kestemberg, and Decobert (1972) describe
this paradox of the anorexic subject who is struggling with an idealized
body (for its thinness), object of desire in one hand and a real body,
object of denial in the other hand. Is it the paradox of the anorexic
subject or the one of the girl sexually assaulted?
Mrs. C. (48 years) explains a posteriori that anorexia nervosa “led me
to drive my femininity off myself and to break the mind and the body
connection”. The bodily sensations disappear and this becomes a sur-
vival strategy against the sexual assault. Because of the rape, libido and
desire disappear and this feeling is reinforced by the anorexia nervosa
and its physiological consequences. Towards the forced use of her body,
the goal is to safeguarding her mind, her soul, her Self, I, while doing
the division between the body and the mind. After the assault, anorexia
nervosa would be the extension of this strategy. This contribute to the
euphoric time explanation and to the feeling that everything becomes
cerebral as explains Mrs. C. (48 years), “anorexia nervosa causes this
phenomenon of rising up, the body forget itself and just the mind exists. It’s
very exhilarating but very dangerous, I felt I could reach death”. The fight
then ensued between the mind and the body sometimes to the point of
living a marked dissociation between the two dimensions of the person.
The subject is in denial of her thinness and of health gravity especially
because this thinness gives a well-being and a control feeling.
The body of the victim is soiled and therefore rejected, the person
does exist only with her cognitive skills. What is the use to give food to
this body which can cause a credible or perceived attack? Why being
physically enviable if it results in becoming a victim of such tragic and
violent consequences? Our analysis confirms the Fallon et al.’s (1994)
study which shown that the sexual abuse victims adopt a restricting
eating behavior because they refuse to see their bodies developed with
secondary sexual characteristics during or after puberty, or because
they want to recover some control on their body.
5. Conclusion and therapeutic prospects
As some studies try to identify the risk populations (Favaro et al.,
2010), it seems difficult to bring out definite predictor factors. The
person is unable to express or manage other than that food deprivation,
“Sometimes I’m hungry between meals, but I prohibited it myself” (Ms. E.,
25 years). We define anorexia nervosa as the symptom and not as the
problem. This perspective will determine the approach and the treat-
ment by the clinical psychologist.
Following Legrand and Briend (2015), psychotherapies could pro-
gress if they avoid the dichotomy to focus on the symptoms or to focus
on the social and familial environment. Indeed, anorexia nervosa
treatment procedures are often focused on the patient’s eating behavior
and any weight gain or loss. It is often forgotten to research the triggers
S. Matt Lacoste Aggression and Violent Behavior 36 (2017) 76–80
79
of the anorexia nervosa for the subject. Is it not because psy-
chotherapies do not treat the origin of anorexia nervosa that this dis-
order has got this high relapse rate?
Even if we don’t deny the biological and neurophysiological im-
plications of the anorexia nervosa, we consider anorexia nervosa as the
expression of a psychic conflict experienced by the person in an op-
position posture. This is a symptom masking a discomfort, a trauma, an
emotional deprivation, an emotional disorder, an identity disorder, an
emotional shock or an internal social conflict. Anorexia nervosa is
rooted in this emotionally fragile people or with difficult life experi-
ences. Often, anorexia nervosa is the physical expression allowing the
nonverbal expression of a generally important psychological disorder.
By the thinness of their body and the visibility of their eating disorder,
patients show that a problem exists but they can decide whether they
will put words on the real problem (family issue, sexual assault, etc.) or
they will stay on struggling only on anorexia nervosa and keep the mask
on the origin of their anorexia nervosa. This eating disorder is a tool
that patients use to have the control, by this way they control their
relative, “I need help but I will say why only if and when I want”. Thus, our
efficient approach is to focus on the “why”. Respond to this question is
to provide another tool than the anorexia nervosa to speak about the
origin(s) of the symptom, and therefore treat all the problem’s con-
sequences by the psychotherapy.
The psychotherapy (inpatient or outpatient) remains the crucial
element in the anorexia nervosa treatment. The psychiatric protocols
with an excessive focus on weight gain are, for us, incomplete and in-
effective. The subject builds her personality and exists by means of her
thinness. If the psychotherapist’s work is focused on the thinness and on
to recover weight, he will reinforce the empowerment of the disease.
Albert Einstein explained that we cannot solve problems by using the same
thinking we used when we created them. As well for Sullivan, Bulik, Fear
and Pickering (1998, p.945), this kind of therapy “neglects the detec-
tion and treatment of associated psychological features and co-
morbidity”. These authors also note a very high lifetime prevalence of
several anxiety disorders. This proves that the problem is not resolved
and that the anorexia nervosa was a psychological expression of this
problem.
For Jeammet (1991) the kind, the quality, the consistency and the
duration of the anorexic subject treatment and accompaniment de-
termine the quality of the disorder recovery with the establishment of a
social, family and sexual life and an eating behavior close of the
“normalcy”. We see in our psychological practices, how much it’s im-
portant for the patient to establish a strong link with the clinician. We
can construct, with this link, a dynamic of work for that healing
journey. For this pathway, we mainly use two engines simultaneously:
the first is to answer to the question of the why? (Why the patient fell in
anorexia nervosa?), and the second is to set goals for short, mid and
long-term. The psychotherapy needs to be focused on the patient in a
holistic approach. We come back to Rogers (1957), in the therapeutic
relationship he turned to interpersonal qualities of the therapist,
namely empathy, unconditional positive regard and congruence. Thus,
focused on the patient, the therapist may provide the necessary con-
ditions for realizing the healing processes and create the ability to bond
or develop attachments in future relationships.
The rates of relapse have to alert us to the emergency of improving
the treatment for anorexia nervosa. The anorexia disorder being gen-
erally the symptom, research of the one or the several causes must be
the major goal of an efficient psychotherapy.
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Introduction
Literature review
Method
Data analysis and discussion
Conclusion and therapeutic prospects
References
www
.
elsevier.com/locate/bodyimage
Body Image 1 (2004) 351–361
Idealized media images and adolescent body image:
‘‘comparing’’ boys and girls
Duane A. Hargreaves*, Marika Tiggemann
School of Psychology, Flinders University of South Australia,
G.P.O. Box 2100, Adelaide 5001, South Australia
Received 25 February 2004; received in revised form 6 October 2004; accepted 10 October 2004
Abstract
Sociocultural theories of body image suggest that body dissatisfaction results from unrealistic societal beauty ideals, and one
way of transmitting these ideals is through the mass media. The present research aimed to examine the effect of exposure to
images of idealized beauty in the media on adolescent girls’ and boys’ body image. The participants (595 adolescents) viewed
television commercials containing either images of the thin ideal for women, images of the muscular ideal for men, or non-
appearance television
commercials.
Body dissatisfaction was measured before and after commercial viewing. It was found that
exposure to idealized commercials led to increased body dissatisfaction for girls but not for boys. Idealized commercials led to
increased negative mood and appearance comparison for girls and boys, although the effect on appearance comparison was
stronger for girls. Further, participants high on appearance investment reported greater appearance comparison after viewing
idealized commercials than those less strongly invested in their appearance. The results suggest the immediate impact
of the media on body image is both stronger and more normative for girls than for boys, but that some boys may also be
affected.
# 2004 Elsevier B.V. All rights reserved.
Keywords: Body dissatisfaction; Mass media; Thin ideal; Muscular ideal; Social comparison
Introduction
Body dissatisfaction, which is common among
women of all ages, is especially prevalent during
adolescence when body image is ‘‘the most important
component’’ of adolescent girls’ self-esteem (Levine
* Corresponding author. Fax: +61 8 8201 3877.
E-mail address: duane.hargreaves@flinders.edu.au
(D.A. Hargreaves).
1740-1445/$ – see front matter # 2004 Elsevier B.V. All rights reserved
doi:10.1016/j.bodyim.2004.10.002
& Smolak, 2002a, p. 77). Arguably the most likely
cause of body dissatisfaction among adolescent girls is
the current unrealistic standard of female beauty
which places an inordinate emphasis on thinness
(Fallon, 1990; Heinberg, 1996; Rodin, Silberstein, &
Striegel-Moore, 1985), and which is unattainable for
most girls (Ackard & Peterson, 2001; Rosenblum &
Lewis, 1999). This ideal standard of beauty is
conveyed to individuals via a number of sources
including family, peers and the mass media (van den
.
D.A. Hargreaves, M. Tiggemann / Body Image 1 (2004) 351–361352
Berg, Thompson, Obremski-Brandon, & Coovert,
2002). The mass media, which include magazines and
television, are often regarded as the single strongest
influencing factor on adolescent body image (e.g.,
Irving, 1990, p. 239; Levine & Smolak, 1996, p. 238;
Mazur, 1986; Raphael & Lacey, 1992; Silverstein,
Perdue, Peterson, & Kelly, 1986).
A small number of studies have examined the
impact of media images on the body image of
adolescents. Correlational studies show that adoles-
cent girls who read more magazines and watch more
television report greater body dissatisfaction (Ander-
son, Huston, Schmitt, Linebarger, & Wright, 2001;
Botta, 1999; Field et al., 1999; Harrison, 2000, 2001;
Hofchire & Greenberg, 2002; Levine, Smolak, &
Hayden, 1994). Experimental studies show that
exposure to idealised media images leads to increased
state body dissatisfaction for girls (Durkin & Paxton,
2002; Groesz, Levine, & Murnen, 2002; Hargreaves &
Tiggemann, 2002, 2003; Stice, Spangler, & Agras,
2001). To date, however, only a few correlational
studies have included boys (Anderson et al., 2001;
Botta, 2003; Harrison, 2000, 2001; Morry & Staska,
2001). While a small number of experimental studies
have found a negative impact of muscular-ideal
magazine images on college-aged men (Grogan,
Williams, & Connor, 1996; Leit, Pope, & Gray,
2002; Ogden & Mundray, 1996, but see Kalodner,
1997), no experimental studies of the media’s
immediate impact on the body image of adolescent
boys have been conducted. Although boys’ body
dissatisfaction is typically less severe than for girls
(e.g., Feingold & Mazzella, 1998; Field, Colditz, &
Peterson, 1997; Muth & Cash, 1997; Thomas,
Ricciardelli, & Williams, 2000), they too express
dissatisfaction with their body weight and appearance
(Cohane & Pope, 2001; Levine & Smolak, 2002a;
Ricciardelli & McCabe, 2001). Such dissatisfaction
has been linked to a number of negative consequences
including the development of dieting, excessive
exercise, and low self-esteem (Olivardia, 2002).
Like girls, the most likely cause of body
dissatisfaction among boys is an unrealistic appear-
ance ideal (Mishkind, Rodin, Silberstein, & Striegel-
Moore, 1986; Westmoreland-Corson & Andersen,
2002). The current ideal male body is lean but highly
muscular, characterised by a ‘‘well-developed chest
and arms, with wide shoulders tapering down to a
narrow waist’’ (Pope et al., 2000, p. 30). Images of this
ideal have become increasingly common in the media
(Pope et al., 2000). For example, compared to 25 years
ago, men are now more often bare chested in
magazines (Pope, Olivardia, Borowiecki, & Cohane,
2001), in accord with increased sexual objectification
of male bodies in mainstream advertising (Rohlinger,
2002). Repeated exposure to images of unrealistically
muscular male ideals may cause men to feel insecure
about their own bodies, parallel to the way in which
exposure to images of unrealistically thin models
promotes body dissatisfaction among girls.
The purpose of the present experiment was to
examine the impact of televised images of idealised
male attractiveness, in addition to female attractive-
ness, on ado
lescent body image.
Effects on the
underlying process, and individual differences in
reaction, were also examined. Social comparison
theory (Festinger, 1954; Suls & Wheeler, 2002; Wood,
1989) would suggest that the mechanism by which
media exposure influences body image is appearance-
related social comparison. Specifically, a number of
authors (Cattarin et al., 2000; Durkin & Paxton, 2002;
Martin & Kennedy, 1993; Richins, 1991; Tiggemann
& McGill, 2004) reason that viewing television, or
reading magazines, prompts individuals to evaluate
their own appearance by comparison to the salient and
highly attractive models who pervade such media.
Because this process leads most individuals to find
themselves wanting, such upward social comparison
produces a negative evaluation of one’s own physical
appearance, resulting in a state-like increase in body
dissatisfaction.
In addition there are likely to be stable individual
differences in comparison tendency relating to
appearance (Wood, 1989). Such differences might
predict who engages in ‘‘state’’ appearance-related
social comparison to media images, and is therefore
most vulnerable to the media’s effect on body image.
Recent evidence suggests girls are more likely to
engage in appearance-related social comparison than
boys (Jones, 2001). Moreover, individuals who have a
trait-like tendency to engage in appearance-related
social comparison (Thompson, Heinberg, & Tantleff,
1991), or who are more strongly invested in their
appearance, sometimes referred to as appearance
schematics (Cash & Labarge, 1996), may be
particularly likely to engage in appearance compar-
D.A. Hargreaves, M. Tiggemann / Body Image 1 (2004) 351–361 353
ison to media images. We propose that these stable
individual difference variables (e.g., trait social
comparison, appearance schematicity, and gender)
interact with characteristics of the media image (e.g.,
salience of the model’s attractiveness) to predict when
media exposure will prompt appearance-related
comparison and increased body dissatisfaction.
To date this perspective has been investigated only
for women and girls. In a recent study, Tiggemann and
McGill (2004) showed that both the experimental
variable of media type (thin-ideal or control) and the
stable individual difference variable of trait social
comparison predicted actual comparison to media
images and increased body dissatisfaction. We believe
this perspective is equally applicable to an under-
standing of men’s and boys’ body image. The present
study used a 2 � 2 between subjects experimental
design to investigate the effects of commercial
condition (thin ideal, muscular ideal, non-appearance
control) and instructional set (appearance-focus,
distracter) on boys’ and girls’ appearance-related
social comparison and state body dissatisfaction. Trait
social comparison and appearance schematicity were
assessed as possible moderating variables. It was
predicted that boys (girls) would report greater body
dissatisfaction and appearance comparison after
viewing muscular-ideal (thin-ideal) commercials than
non-appearance commercials, and that adolescents
high on trait social comparison and appearance
schematicity would be most strongly affected.
1
Although some girls (n = 128) viewed the muscular-ideal
commercials, and some boys (n = 125) viewed thin-ideal commer-
cials, the results for these participants are not reported.
Method
Participants
The participants were 595 adolescent students (310
girls, 285 boys) from two South Australian metropo-
litan coeducation public high schools of medium
socio-economic status. Students were in years 8–12
and with a mean age of 14.3 years (SD = 1.4).
Participants were allocated to the thin-ideal, muscular-
ideal, or non-appearance commercial condition by
random allocation of class group (n = 42), and were
randomly allocated to the instructional set conditions
on an individual basis. This procedure resulted in a
total of 153 girls in the thin-ideal commercial
condition, 157 girls in the non-appearance commercial
condition, 146 boys in the muscular-ideal commercial
condition, and 139 boys in the non-appearance
commercial condition
1
.
Materials
State mood and body dissatisfaction
A number of visual analogue scales (VAS) were
used as measures of body dissatisfaction and mood.
Participants were asked to indicate how they feel
‘‘right now’’ on a series of four mood dimensions:
‘‘Happy’’; ‘‘Worried’’; ‘‘Confident’’; and ‘‘Angry’’;
and four dimensions of body satisfaction: ‘‘Fat’’;
‘‘Strong’’; ‘‘Dissatisfied (unhappy) with weight and
shape’’ and ‘‘Dissatisfied (unhappy) with overall
appearance’’. Each participant completed the VAS on
two occasions: 5 min before commercial viewing and
immediately after commercial viewing. VAS scores,
which are measured to the nearest mm, have been
previously shown to correlate significantly with longer
measures of mood and body dissatisfaction (Heinberg
& Thompson, 1995).
Three of the four body dissatisfaction VAS were
significantly intercorrelated (rs > 0.52, p < 0.001) and so were combined to form a composite state
body dissatisfaction variable. The three-item scale
(weight dissatisfaction, appearance dissatisfaction,
fat) displayed very good internal consistency for the
present sample, a = 0.85. Intercorrelations between
the four mood VAS were also significant (rs > 0.24,
p < 0.001), and so were combined to form a
composite mood variable (happy and confident were
reverse coded, such that higher scores reflect greater
negative affect). The four-item negative-mood scale
showed acceptable internal consistency for the present
sample, a = 0.66. The composite state body dissa-
tisfaction and negative mood variables were signifi-
cantly positively correlated, r = 0.42, p < 0.001.
State appearance comparison
A series of self-report items, based on Tiggemann
and McGill (2004), assessed appearance-related social
comparison during commercial viewing. Participants
were asked to use a Likert scale ranging from 1 = not
D.A. Hargreaves, M. Tiggemann / Body Image 1 (2004) 351–361354
at all to 7 = very much to indicate what they had
thought about while viewing the commercials. The
five items assessed how much they: (1) thought about
the qualities of the commercials; (2) thought about the
effectiveness of the commercials; (3) thought about
the attractiveness of the people in the commercials; (4)
compared their own appearance to the actors in the
commercials; and (5) wanted to be like the actors in
the commercials. Questions 2 and 3 served as a
manipulation check of the instructional set which
asked participants to rate the ‘‘effectiveness of the
commercials’’ (Question 2) or the ‘‘attractiveness of
actors in the commercials’’ (Question 3). Responses to
Question 4 formed the single-item state appearance
comparison variable.
Appearance schematicity
The Appearance Schemas Inventory (ASI) (Cash &
Labarge, 1996) was used to measure appearance
schematicity. Using a five-point Likert scale ranging
from 1 = strongly disagree to 5 = strongly agree,
respondents indicate their level of agreement with 14
statements (e.g., ‘‘What I look like is an important part
of who I am’’, ‘‘Attractive people have it all’’), such
that high scores reflect higher appearance schemati-
city. Tests of internal consistency for the present
sample showed good reliability for both girls
(a = 0.86) and boys (a = 0.81).
Trait social comparison
The Physical Appearance Comparison Scale
(PACS) (Thompson et al., 1991) measures the degree
to which individuals tend to compare their appearance
with others. Participants indicate their agreement with
five statements (e.g., ‘‘In social situations, I compare
my figure to the figure of other people’’) using a five-
point scale ranging from 1 = never to 5 = always.
Tests of internal consistency for the present sample
showed good reliability for both girls (a = 0.84) and
boys (a = 0.79). Both trait social comparison and
appearance schematicity were measured approxi-
mately 15 min after participants completed the
dependent measures.
Experimental manipulation: videotape stimulus
Three sets of video stimulus materials were compiled,
each containing 18 television commercials. In the first
set, referred to as thin-ideal commercials, 15 of the 18
commercials contained female actors who ‘‘epitomise
societal ideals of thinness and attractiveness’’ for women
(Heinberg & Thompson, 1995, p. 331). The actors were
typically well-toned, tanned, free of body hair, well-
groomed, youthful, large-breasted and, most impor-
tantly, thin. The second set of television commercials,
referred to as muscular-ideal commercials, was similar
to the first in terms of product category and judged
effectiveness, but contained images of men who
epitomise societal ideals of muscularity and attractive-
ness. The men typically had well-built, tanned, and toned
upper bodies. The men were also bare-chested for all or
part of the commercial in the majority of selected
commercials (11 out of 15). The third set of commercials
contained no actors who epitomised either the
thin ideal for women or the muscular ideal for men.
To ensure that these commercials (control condition)
were of equal interest to viewers, they were matched to
the first two sets on both effectiveness and product
category.
The commercials were collected from Australian
prime-time television. A pilot tape of 145 commer-
cials (grouped into nine product categories: clothing;
food and drink; music; movies and television;
cosmetics and health; cars; communications and
electronics; finance, banking, and insurance; other)
was shown to 12 (six female and six male) under-
graduates (M age = 19.3, SD = 1.7). The students rated
each commercial on three seven-point scales accord-
ing to the following criteria: (1) ‘‘to what extent do the
actors epitomise the current thin ideal for women?’’
(2) ‘‘to what extent do the actors epitomise the current
muscular-attractiveness ideal for men?’’ and (3) ‘‘how
effective is the commercial?’’ Using these ratings, the
15 commercials that most epitomised the muscular
ideal for men were chosen first (due to their lower
availability). The 15 commercials that most epito-
mised the thin ideal for women, and were of
comparable effectiveness and product type, were then
matched to these commercials and, finally 15
commercials that contained women and men of
‘‘normal’’ appearance were matched to these com-
mercial sets. The product categories were also
matched where possible. A further three non-
appearance commercials were selected and included
in all three commercial sets to help disguise the
purpose of the study.
D.A. Hargreaves, M. Tiggemann / Body Image 1 (2004) 351–361 355
Experimental manipulation: instructional set
Instructions for viewing the commercials were
manipulated using a commercial rating task. Half the
participants were asked to rate the attractiveness of the
actors (appearance focus condition) in each commer-
cial using a five-point scale ranging from 1 = not at all
attractive to 5 = extremely attractive. This instruction
was designed to explicitly focus participants’ attention
on appearance-related aspects of the commercials. In
contrast, the other half of participants (distracter
condition) were asked to rate the overall effectiveness
of each commercial (1 = not at all effective, 5 = extre-
mely effective), and as such were explicitly asked to
focus on non-appearance-related content of the
commercials.
Results
The effect of television commercials on girls’ and
boys’ body dissatisfaction
The adjusted means (controlling for pre-commer-
cial state) for girls and boys after commercial viewing
on the body dissatisfaction outcome variable (average
of fat, weight dissatisfaction, appearance dissatis-
faction) are presented in Table 1. A 2 (Gender) � 2
(commercial condition) � 2 (Instructional set)
ANCOVA (controlling for the pre-commercial vari-
Table 1
Adjusted mean (standard errors in parentheses) body dissatisfaction
among girls and boys after commercial viewing
Variable Non-App Ideal Total
Girls
Distracter 26.6 (1.18) 31.6 (1.21) 29.1 (0.85)
Appearance focus 28.8 (1.20) 33.7 (1.20 31.3 (0.86)
Total 27.7 (0.84) 32.7 (0.86) 30.2 (0.61)
Boys
Distracter 25.1 (1.25) 22.4 (1.26) 23.8 (0.90)
Appearance focus 27.2 (1.28) 27.8 (1.20) 27.5 (0.88)
Total 26.1 (0.91) 25.1 (0.87) 25.6 (0.64)
Combined
Distracter 25.8 (0.86) 27.0 (0.87) 26.4 (0.61)
Appearance focus 28.0 (0.87) 30.8 (0.84) 29.4 (0.60)
Total 26.9 (0.61) 28.9 (0.61) 27.9 (0.43)
able) was conducted to test the prediction that viewing
thin/muscular-ideal commercials would lead to
greater body dissatisfaction than viewing non-appear-
ance-related commercials. The results show signifi-
cant main effects of gender, F(1, 586) = 25.20,
p < 0.001, eta2 = 0.04, commercial condition, F(1, 586) = 5.34, p < 0.05, eta2 = 0.01, and instructional set, F(1, 586) = 11.87, p < 0.05, eta2 = 0.02. The appearance focus instructions produced more body
dissatisfaction than the distracter instructions. The
main effects of gender and commercial condition were
modified by a significant Gender � Commercial
condition interaction, F(1, 586) = 12.26, p < 0.001,
eta
2
= 0.02. As predicted, girls viewing thin-ideal
commercials had significantly greater body dissatis-
faction (M = 32.7) than those viewing the non-
appearance commercials (M = 27.7), F(1, 307) =
16.08, p < 0.001, eta2 = 0.05. In contrast, boys in the muscular-ideal condition did not report greater
body dissatisfaction (M = 25.1) than boys in the non-
appearance condition (M = 26.1), F(1, 282) < 1,
p > 0.05. There were no further significant two- or
three-way interactions, Fs < 1.04, p > 0.05.
The effect of television commercials on girls’ and
boys’ state mood
Table 2 presents the adjusted means (controlling for
pre-commercial state) for girls and boys after
commercial viewing on the negative mood outcome
Table 2
Adjusted mean (standard errors in parentheses) negative mood
among girls and boys after commercial viewing
Variable Non-App Ideal Total
Girls
Distracter 21.7 (1.05) 23.6 (1.08) 22.6 (0.76)
Appearance focus 22.4 (1.07) 26.1 (1.06) 24.3 (0.75)
Total 22.1 (0.75) 24.8 (0.76) 23.5 (0.53)
Boys
Distracter 19.6 (1.11) 21.3 (1.13) 20.5 (0.79)
Appearance focus 19.0 (1.15) 21.4 (1.07) 20.2 (0.79)
Total 19.3 (0.80) 21.4 (0.78) 20.3 (0.56)
Combined
Distracter 20.7 (0.77) 22.5 (0.78) 21.6 (0.55)
Appearance focus 20.7 (0.78) 23.8 (0.75) 22.2 (0.54)
Total 20.7 (0.55) 23.1 (0.54) 21.9 (0.39)
D.A. Hargreaves, M. Tiggemann / Body Image 1 (2004) 351–361356
variable (average of happy, worried, confident, angry).
The results of a 2 (Gender) � 2 (Commercial
condition) � 2 (Instructional set) ANCOVA (control-
ling for the pre-commercial variable) show that girls
(M = 23.5) reported greater negative mood than boys
(M = 20.3), F(1, 586) = 16.46, p < 0.001, eta2 = 0.03, and that girls and boys in the ideal appearance
condition reported significantly greater negative mood
(M = 23.1) than girls and boys in the non-appearance
condition (M = 20.7), F(1, 586) = 9.98, p < 0.01, eta
2
= 0.02. There were no further significant effects,
Fs < 1.50.
The effect of television commercials on girls’ and
boys’ appearance comparison
The processing measure of appearance comparison
was assessed only after commercial exposure. Mean
appearance comparison scores for girls and boys are
presented in Table 3. A 2 (Gender) � 2 (Commercial
condition) � 2 (Instructional set) ANOVA revealed a
main effect of gender whereby, irrespective of
experimental condition, girls engaged in greater
appearance comparison (M = 2.51, SD = 1.70) than
boys (M = 2.07, SD = 1.35), F(1, 583) = 14.38,
p < .001, eta2 = 0.02. There was also a significant main effect of commercial condition whereby
participants in the ideal appearance condition engaged
in greater appearance comparison (M = 2.72) than
participants in the non-appearance condition
Table 3
Mean (standard deviations in parentheses) self-reported state
appearance comparison with commercials by girls and boys
Variable Non-App Ideal Total
Girls
Distracter 1.97 (1.18) 2.99 (1.89) 2.47 (1.64)
Appearance focus 1.87 (1.06) 3.24 (2.04) 2.56 (1.76)
Total 1.92 (1.12) 3.12 (1.97) 2.51 (1.70)
Boys
Distracter 1.66 (1.18) 2.10 (1.20) 1.88 (1.21)
Appearance focus 2.00 (1.41) 2.47 (1.47) 2.25 (1.46)
Total 1.83 (1.31) 2.30 (1.36) 2.07 (1.35)
Combined
Distracter 1.83 (1.18) 2.57 (1.66) 2.19 (1.48)
Appearance focus 1.93 (1.24) 2.86 (1.82) 2.41 (1.63)
Total 1.88 (1.21) 2.72 (1.75) 2.30 (1.56)
(M = 1.88), F(1, 583) = 45.81, p < 0.001, eta2 = 0.07. But the main effects of gender and commercial
condition should be interpreted in light of a significant
Gender � Commercial condition interaction, F(1,
183) = 9.20, p < 0.01, eta2 = 0.02. It can be seen in
Table 3 that idealized appearance commercials led to
greater appearance comparison for girls than for boys,
F(1, 296) = 17.39, p < 0.001, eta2 = 0.06, but that girls and boys did not differ in the non-appearance
condition, F(1, 291) < 1, p > 0.05. There was no
significant main effect of instructional set, F(1,
583) = 3.10, p > 0.05, nor significant interaction of
instructional set with either gender or commercial
condition, Fs < 1.27.
Trait social comparison and appearance schematicity
as moderating variables
Appearance schematicity and trait social compar-
ison were highly correlated for both girls, r = 0.68,
p < 0.001, and boys, r = 0.60, p < 0.001. Thus, the two scales were averaged to form a single appearance
investment variable. An independent samples t-test
showed that girls reported greater appearance invest-
ment (M = 2.63, SD = 0.74) than boys (M = 2.33,
SD = 0.63), t(589) = 5.28, p < .001, eta2 = 0.05. As is often done (e.g., Lavin & Cash, 2001) participants
were then divided into tertiles based on their
appearance investment score. Participants in the low
appearance investment group (102 girls and 125 boys)
scored between 1 and 2.24, participants in the medium
group scored (98 girls and 101 boys) between 2.25 and
2.99, and participants in the high investment group
(103 girls and 54 boys) scored between 3.00 and 5.00.
A series of 2 (Gender) � 2 (Commercial con-
dition) � 3 (Appearance investment) ANCOVAs was
conducted to examine the hypothesis that participants
higher on appearance schematicity and trait social
comparison would be most negatively affected by
thin-ideal/muscular-ideal commercials. The results for
body dissatisfaction show a significant main effect of
gender, F(1, 570) = 22.19, p < 0.001, eta2 = 0.04, commercial condition, F(1, 570) = 6.33, p < 0.05, eta
2
= 0.01, and appearance investment, F(2,
570) = 9.07, p < 0.001, eta2 = 0.03, and a significant Gender � Commercial condition interaction, F(2, 570) = 7.65, p < 0.01, eta2 = 0.01. There were no other significant 2-way or 3-way interaction, F(2,
D.A. Hargreaves, M. Tiggemann / Body Image 1 (2004) 351–361 357
570) = 2.27, p > 0.05. A second ANCOVA for mood
showed a significant main effect of gender, F(1,
570) = 10.84, p < 0.001, eta2 = 0.02, and commercial condition, F(1, 570) = 8.09, p < 0.01, eta
2
= 0.01, but
not appearance investment, F(2, 570) = 1.59,
p > 0.05, eta2 = 0.01. No two- or three-way interac-
tion was significant, F(2, 570) < 1.13, p > 0.05.
Lastly, a 2 (Gender) � 2 (Commercial con-
dition) � 3 (Appearance investment) ANOVA was
conducted to examine the moderating role of
appearance investment on the level of appearance
comparison. The results show a significant main effect
of gender, F(1, 567) = 6.36, p < 0.05, eta2 = 0.01, commercial condition, F(1, 567) = 53.32, p < 0.001, eta
2
= 0.09, and appearance investment, F(2,
567) = 50.10, p < 0.001, eta2 = 0.15, and significant two-way interactions between Gender and Commer-
cial condition, F(2, 567) = 6.41, p < 0.05, eta2 = 0.01, and Appearance investment and Commercial condi-
tion, F(2, 567) = 7.24, p < 0.001, eta 2
= 0.03. Fig. 1
shows that participants high on appearance investment
reported greater appearance-related social comparison
with the commercials than participants in the medium
and low appearance investment groups, and that
this effect was larger in the ideal condition, F(2,
Fig. 1. Effect of commercials on appearance comparison for girls
291) = 49.05, p < 0.001, eta2 = 0.25, than in the non- appearance condition, F(2, 282) = 14.86, p < 0.001, eta
2
= 0.10.
Discussion
The present study has replicated the results of
previous research for adolescent girls (Durkin &
Paxton, 2002; Groesz et al., 2002; Hargreaves &
Tiggemann, 2002, 2003; Stice et al., 2001). As
predicted, exposure to thin-ideal commercials led to
significantly greater body dissatisfaction and negative
affect among girls than non-appearance commercials.
Although the effect sizes were only small, the results
are consistent with the conclusion that exposure to
thin-ideal media has a small and reliable negative
effect on girls (Groesz et al., 2002).
But the main purpose of the study was to examine
the effect of idealized images of male attractiveness on
adolescent boys, which has been largely neglected in
previous research. The results show that muscular-
ideal television commercials had only a limited impact
on boys’ body image, and on average, exposure to
muscular-ideal commercials did not lead to increased
and boys low, medium, and high on appearance investment.
D.A. Hargreaves, M. Tiggemann / Body Image 1 (2004) 351–361358
body dissatisfaction. This finding was in contrast to
some previous studies that found a negative impact of
muscular-ideal magazine images on college-aged men
(Grogan et al., 1996; Leit et al., 2002; Ogden &
Mundray, 1996, but see Kalodner, 1997)
2
. It could be
that males do not develop a vulnerability to muscular-
ideal media images until late adolescence or early
adulthood, perhaps due to developmental changes in
the salience of muscularity concerns.
A second important purpose of the study was to
examine the role of social comparison processes for
understanding the media’s impact. While exposure to
thin-ideal and muscular-ideal commercials did lead
to increased appearance comparison, this effect was
stronger for girls. These results suggest that, in
general, girls seem to process self-related appearance
information more deeply and more automatically than
boys. Interestingly, however, it was both girls and boys
high on appearance investment who were most likely
to engage in appearance comparison to the commer-
cials, and to the idealized commercials in particular.
Thus, it is important to recognise the role of both
gender and appearance investment in understanding
the process of social comparison to media images.
Overall the results suggest that the media’s
immediate impact on body image is both stronger
and more normative for girls than boys. This pattern of
results reflects the general pattern of gender differ-
ences in the body image literature (see Levine &
Smolak, 2002a), suggesting that boys’ body image
experiences mirror those of girls but are typically less
prevalent, and when present, less severe. However,
some methodological limitations of the current
research need to be acknowledged. First, the
comparison of the media’s effect on girls’ and boys’
body dissatisfaction is limited by the content of the
experimental stimuli. Because the media’s portrayal of
the thin ideal is likely stronger and more prevalent
than the muscular ideal, it was not possible to perfectly
match the actors in the thin-ideal and muscular-ideal
commercial tapes. Although the difference between
experimental conditions reflects an actual difference
2
Interestingly, the same set of 15 muscular-ideal commercials
led to increased muscle dissatisfaction and decreased self-perceived
‘‘physical attractiveness’’ for college-aged men (Hargreaves &
Tiggemann, submitted for publication). Taken together, the results
suggest males might not develop a vulnerability to muscular-ideal
media images until later adolescence or early adulthood.
in the prevalence of female and male beauty ideals
(Andersen & DiDomenico, 1992), it is possible that
the effect of idealised commercials on boys would be
stronger if the muscular ideal were more salient. As
the media’s portrayal of the muscular ideal becomes
increasingly pervasive (Pope et al., 2001), it is possible
that boys and men will become increasingly vulner-
able to the impact of idealised images on their body
image. Second, the measurement of boys’ body image
remains a challenge. Although some boys are willing
to acknowledge body image concerns, many boys feel
uncomfortable expressing feelings of dissatisfaction
about their appearance (Pope et al., 2000). Thus,
future research with boys should seek to overcome this
social inhibition. Future studies should also use the
revised ASI (Cash, Melnyk, & Hrabosky, 2004),
published after the completion of this study, for an
improved assessment of appearance investment.
The results of the present research converge with
findings of previous correlational and experimental
research to suggest that mass media contribute to the
development of adolescent girls’ body image. Accord-
ingly, attempts to prevent or reduce body dissatisfac-
tion among adolescents might usefully focus on the
role of the mass media. To date, such programs have
typically targeted girls’ body image (for a review, see
Levine & Piran, 2001). Based on the results presented
here, it is not clear that a similar intervention to target
boys’ body image and the portrayal of the male
muscular ideal is needed. It is also not at all clear
whether current strategies used to combat the media’s
impact on girls (for recent reviews see Levine &
Smolak, 2002b; Winzelberg, Abascal, & Taylor, 2002)
are appropriate for boys. As Winzelberg et al. note, ‘‘it
is likely that many of the programs would need
significant modification for boys [or men] to find them
acceptable’’ (p. 494). A modified mode of delivery, as
well as modified content, would be necessary, as many
boys are likely to resist participation making class-
room interventions difficult. Due to this likely
resistance from boys, an important step in designing
an intervention might be to ask boys about the type of
program in which they are willing to participate. For
example, in an attempt to improve the effectiveness of
body image programs for girls, Paxton, Wertheim,
Pilawski, Durkin, and Holt (2002) asked adolescent
girls which messages would be most acceptable (i.e.,
relevant, believable). Similar research with adolescent
D.A. Hargreaves, M. Tiggemann / Body Image 1 (2004) 351–361 359
boys is needed to ensure the development of
intervention programs that boys will find acceptable,
credible, and relevant.
In summary, the present results suggest that
unrealistic ideals of beauty in the media are an
important source of social comparison, and a possible
cause of body dissatisfaction among certain girls and
boys. It remains unclear how these short-lasting
effects might generalize to real world media exposure.
However, as a whole, the results support the usefulness
of social comparison theory, which proposes appear-
ance comparison as an underlying process by which
the media can increase body dissatisfaction, and
appearance schematicity/trait social comparison as
explanations as to why some adolescents are more
vulnerable than others to the media’s immediate
effect. Future investigations of gender differences in
response to media images will contribute to our
growing understanding of the development of ado-
lescent body image.
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Introduction
Method
Participants
Materials
State mood and body dissatisfaction
State appearance comparison
Appearance schematicity
Trait social comparison
Experimental manipulation: videotape stimulus
Experimental manipulation: instructional set
Results
The effect of television commercials on girls? and boys? body dissatisfaction
The effect of television commercials on girls? and boys? state mood
The effect of television commercials on girls? and boys? appearance comparison
Trait social comparison and appearance schematicity as moderating variables
Discussion
References
O R I G I N A L P A P E R
Parental Influences on Elite Aesthetic Athletes’ Body Image
Dissatisfaction and Disordered Eating
Rita Francisco • Isabel Narciso • Madalena Alarcão
Published online: 10 October 2012
� Springer Science+Business Media New York 2012
Abstract Although different forms of parental influences
on adolescents’ body image and eating disturbances have
been studied, this relationship is nearly uninvestigated
within the population of aesthetic athletes, a risk group for
the development of eating disorders. The present study
examined the role of specific family variables on the body
image dissatisfaction (BID) and disordered eating (DE) of
elite aesthetic athletes (n = 85) and controls (n = 142).
Adolescents (M = 14.87 years, SD = 2.22) completed
measures of direct influences (concern with thinness and
weight teasing by parents), perceived quality of relation-
ship with each parent and the overall family environment,
BID and DE. Participants’ parents (223 mothers and 198
fathers) also completed measures of BID and DE. In gen-
eral, parents of athletes do not present higher levels of BID
or DE than do controls’ parents. Interesting differences
were found between athletes’ and controls’ BID and DE
predictors. Among athletes, direct parental influences are
the only significant predictive family variable, which can
reinforce the pressure to be thin found within elite-aesthetic
contexts. The study’s findings highlight not only the
importance of critical parental comments in athletes’
expression of BID and DE, but also of maternal modeling
among adolescents in the general population. Such parental
behavior may be an appropriate target in different pre-
vention efforts.
Keywords Aesthetic athletes � Parental influences � Body
image dissatisfaction � Disordered eating � Predictors
Introduction
The impact of family influence on the development of body
image and eating disturbances has been identified by several
studies with patients diagnosed with eating disorders (e.g.,
Latzer et al. 2002; Minuchin et al. 1978) as well as with the
general adolescent and young adult population (Vincent and
McCabe 2000; Yanez et al. 2007). The only literature review
to date about parental influence merely includes studies in
the general population (Rodgers and Chabrol 2009) because,
in clinical samples, parents’ behaviors and attitudes regard-
ing weight, eating and body image can be influenced by their
child’s diagnosis or therapeutic interventions. Most of these
studies have been conducted exclusively with female ado-
lescents and their mothers; however, data suggest that both
mothers and fathers are important sources of influence for
their child’s body image and eating habits, regardless of that
child’s gender. Furthermore, this influence may take place
via different mechanisms.
The first mechanism, which has received much atten-
tion, concerns the direct transmission of weight-related
attitudes and opinions from parent to child. Both cross-
sectional and longitudinal studies conducted with preado-
lescents and adolescents show that critical negative com-
ments about eating and weight are predictors of body
image dissatisfaction, weight concerns and disordered
eating (Ata et al. 2007; Kluck 2010; Pike and Rodin 1991;
Smolak et al. 1999; Wertheim et al. 2002). Conversely,
studies have also demonstrated that lower levels of disor-
dered eating are associated with the perception of more
positive messages regarding eating and weight (Gross and
R. Francisco (&) � I. Narciso
Faculty of Psychology, University of Lisbon,
Alameda da Universidade, 1649-013 Lisbon, Portugal
e-mail: rmfrancisco@fp.ul.pt
M. Alarcão
Faculty of Psychology and Education Sciences,
University of Coimbra, Coimbra, Portugal
123
J Child Fam Stud (2013) 22:1082–1091
DOI 10.1007/s10826-012-9670-5
Nelson 2000; Kichler and Crowther 2009). In fact, this
influence can have several long-term effects, not only on
body dissatisfaction and disordered eating but also on self-
esteem and depressive symptoms. These effects have been
shown by some retrospective studies in which undergrad-
uate students reported their experiences about parental
weight-related teasing in childhood and adolescence
(Benas and Gibb 2008; Taylor et al. 2006). Vincent and
McCabe (2000) revealed some specific features of the
influence of each parent on his or her children’s disordered
eating. Specifically, discussion with both parents on topics
related to weight or diet and parental encouragement of
weight loss proved to be predictors of disordered eating
among girls; however, for boys, only maternal encour-
agement predicted weight loss behaviors and binge eating.
Given these differences, future research should include the
participation of both mothers and fathers.
Another important mechanism of parental influence is
modeling of dysfunctional eating attitudes and behaviors.
Several studies with adolescent girls and their parents have
shown significant associations between abnormal eating
attitudes of mothers and daughters (Pike and Rodin 1991;
Vincent and McCabe 2000); however, the same association
does not exist with fathers when they are included (Keel
et al. 1997; Yanez et al. 2007). As it is still unclear whether
parental eating behaviors are associated with dysfunctional
eating behaviors in adolescent boys (Keery et al. 2006;
Vincent and McCabe 2000), the influence of parent gender
on problem eating behaviors needs to be clarified among
both boys and girls.
The final form of parental influence referred to in
existing literature is the quality of family relationships,
primarily overall family environment and relationships
with parents. Family connectedness has been associated
with higher body satisfaction in both boys and girls
(Boutelle et al. 2009; Crespo et al. 2010). Additionally,
several specific aspects of the relationships that adolescents
have with each parent have proven to be rather important.
May et al. (2006) identified different dimensions of
maternal relationships, such as decreased intimacy and
knowledge of children’s daily experiences, as predictors of
weight concerns in young girls. However, the authors
suggested that parent–adolescent conflict is the most
important relationship-quality factor linked to adolescent
weight concerns. Additionally, other studies conducted
only with girls have shown that perceptions of negative
parental relationships are associated with less healthy
dieting and body image, thus highlighting the role of
relationships with both mothers and fathers in the devel-
opment of healthy or disordered eating of adolescent girls
(Archibald et al. 1999; Swarr and Richards 1996).
The world of aesthetic sports—‘‘sports usually thought of
as ‘appearance’ sports in which the sport participant’s
appearance as well as her sport performance is being judged’’
(R. Thompson and Sherman 2010, p. 211), such as dance,
figure skating or gymnastics—is considered a high risk
context for the development of eating disorders among
adolescents (e.g., Byrne and McLean 2002; Francisco et al.
2012; Sundgot-Borgen and Torstveit 2004). The adolescents
who practice elite aesthetic sports are subject to additional
pressures from coaches and are frequent targets of critical
comments pressuring them to be thin and to control weight
and body shape to achieve excellence in performance (Kerr
et al. 2006; Muscat and Long 2008). In fact, many studies
suggest that coaches have a major influence on the body
image and eating behaviors of athletes (Byrne and McLean
2002; Toro et al. 2009). However, the influence of parents on
the body dissatisfaction and disordered eating of their aes-
thetic-athlete children remains unknown. In 2001 (Klump,
Ringham, Marcus, and Kaye), a study on female ballet
dancers showed that dancers had significantly higher levels
of family history of eating disorders than participants in a
control group, reinforcing the need to conduct studies with
athletes that include family variables, as pointed by some
authors (Ringham et al. 2006; Thomas et al. 2005).
To our knowledge, only two other studies examine the
families of athletes in non-aesthetic sports. Of these, only
one evaluated the relationship between eating behaviors of
mothers and athlete daughters, which was conducted with
competitive (but not elite) tennis players and did not show an
association between the eating behaviors of mothers and
their athlete daughters (Harris and Foltz 1999). The other,
more recent study found greater body image disturbance and
higher levels of disturbed eating attitudes among female and
male college athletes who reported family climates with low
perceived support and autonomy (Blackmer et al. 2011).
In a previous study about individual and relational risk
factors (e.g., self-esteem, social pressure for thinness), we
found direct parental influences (e.g., weight teasing) on
disordered eating among elite aesthetic athletes but not on
that of non-elite aesthetic athletes or participants in the
control group (Francisco et al. 2012). Furthermore, we posit
that the quality of family relations, as well as the way ath-
letes’ parents deal with their own body image and eating,
may influence athletes’ perception of messages transmitted
in these high-risk contexts, and the impact of these mes-
sages on body image dissatisfaction and eating behaviors.
The purpose of the present study was to explore the role of
specific family variables in elite aesthetic athletes’ body
image dissatisfaction and disordered eating. We evaluate
body image dissatisfaction and disordered eating patterns of
each parent as well as the adolescent. We also assess ado-
lescents’ perceptions of other family variables: parent con-
cern with their child’s thinness and parental weight teasing,
the perceived quality of maternal/paternal relationships, and
the perceived quality of family environment. Because
J Child Fam Stud (2013) 22:1082–1091 1083
123
previous research was mainly developed with adolescents
from the general population, four different objectives were
identified within this study: (1) to examine differences
between elite aesthetic athletes and controls in body image
dissatisfaction, disordered eating and family variables; (2) to
examine the correlations between parental and adolescents
variables in populations of elite aesthetic athletes and control
participants; (3) to investigate different possible family-
oriented predictors of body image dissatisfaction and dis-
ordered eating for elite aesthetic athletes and controls; and
(4) to examine differences in family characteristics of both
the elite aesthetic athletes and controls, with and without
clinical indication of disordered eating.
Method
Participants
The study involves 227 adolescents of both sexes—85 ath-
letes (M = 15.35 years, SD = 2.73; 70.6 % females) and
142 controls (M = 14.58 years, SD = 1.81; 57.7 %
females)—and their parents (223 mothers, M = 44.71 years,
SD = 5.34; 198 fathers, M = 47.25 years, SD = 6.43). The
elite aesthetic athletes are gymnasts participating in interna-
tional competitions (n = 44; 63.6 % females) and profes-
sional dance students (n = 41; 78 % females).
The majority of participants (79.3 %) come from intact
nuclear families, 11.1 % from single-parent families and
the remainder from other family configurations. The par-
ticipants live in various regions in Portugal, including the
center (48 %), the Lisbon metropolitan area (47.6 %), the
north (3.5 %) and the south (0.9 %). The participants
represent part of a sample from a previous study on pre-
dictive risk factors of disordered eating (Francisco et al.
2012), specifically participants whose parents returned
parent self-report questionnaires (elite athletes’ parents’
response rate 65 %; controls’ parents’ response rate 30 %).
Measures
Measures Completed by
Adolescents
McKnight Risk Factor Survey-IV (MRFS-IV; The
McKnight Investigators 2003) The MRFS-IV is a self-
report questionnaire that assesses potential risk factors for
the development of eating disorders. The Portuguese version
(Francisco et al. 2011) used in the present study consists of 82
items (most of them rated on a 5-point Likert scale, from
‘‘Never’’ to ‘‘Always’’), organized into eight indicators and
nine factors. The ‘‘Parental Influences’’ factor (the only one
of MRFS-IV related to family influences), consisting of four
items—‘‘In the past year, how often has your father (mother)
made a comment to you about your weight or your eating that
made you feel bad?’’ and ‘‘In the past year, how important
has it been to your father (mother) that you be thin?’’—is
used to evaluate the influence of parent concern with thinness
and weight teasing by parents (a = .72).
Perception of Parent–Child Relationships Quality and of
Family Environment Through three items rated on a
5-point Likert scale (from ‘‘Very bad’’ to ‘‘Very well/
good’’), adolescents are questioned about their perception
of the quality of their relationship with each parent—’’How
is your relationship with your father (mother)?’’—and the
quality of their family environment—’’How is your family
environment?’’.
Measures Completed by Both Adolescents and Parents
Contour Drawing Rating Scale (CDRS, Thompson and
Gray 1995) Body image dissatisfaction (BID) was
assessed by the Portuguese version of CDRS (Francisco
et al., in press), consisting of a sequence of nine silhouettes
ordered from the thinnest to the largest. The participants
choose silhouettes that represent their current and ideal
body size. The discrepancy between these two is an indi-
cator of BID. The CDRS has good test–retest reliability
(r = .91) and construct validity (r = .65 with weight;
r = .72 with BMI) among both adolescents and adults.
Eating Disorder Examination-Questionnaire (EDE-Q,
Fairburn and Beglin 1994) The level of disordered eating
(DE), understood in a continuum, was evaluated using the
Portuguese version of the 5th edition of EDE-Q (Machado
and Martins 2010). This is a self-report questionnaire of 28
items grouped into four subscales (‘‘Restraint’’, a = .87;
‘‘Shape Concern’’, a = .91; ‘‘Eating Concern’’, a = .86;
and ‘‘Weight Concern’’, a = .82), the average of which
constitutes a global score (a = .95). The items are rated on a
7-point Likert scale (from ‘‘None’’/’’Nothing’’ to ‘‘Every-
day’’/’’Extremely’’). In the current study, the EDE-Q showed
good psychometric properties with greater internal consis-
tency values in the sample of adolescents than in the sample
of parents [Global Score (adolescents a = .92; parents
a = .83), Restraint (adolescents a = .81; parents a = .75),
Shape Concern (adolescents a = .91; parents a = .86),
Eating Concern (adolescents a = .77; parents a = .68) and
Weight Concern (adolescents a = .84; parents a = .75)].
Procedure
All participants completed an informed consent process
before answering the surveys. In order for adolescents to
participate, authorization was sought from their parents/
guardians. The main researcher delivered athlete surveys to
1084 J Child Fam Stud (2013) 22:1082–1091
123
the dance teachers/gymnastics coaches, who in turn handed
the surveys to their students/gymnasts. Most athletes
completed the surveys at home. The surveys were later
returned in sealed envelopes with no identifying informa-
tion, thus preserving anonymity. All adolescents in the
control group completed the surveys during normal classes
at their schools in the presence of the main researcher. All
parents received their surveys (with a code matching that of
their child) via their children, who, in turn, returned them
to the research group a week later in a sealed envelope.
Permission to conduct the study was provided by the
Ministries of Science (FCT) and of Education.
Statistical Analyses
Statistical analyses were conducted using SPSS 18.0. We
used the Kruskal–Wallis test to compare athletes and
controls on all study variables, given the small sample size
of male athletes (n \ 30). Chi-square test examined cate-
gorical frequencies, and the relationships between the
variables were investigated using Spearman correlations.
Separate multiple regressions were used to investigate
which parental and family variables predict adolescents’
BID and DE for athletes and controls. For each of the
dependent variables (BID and DE), we previously con-
ducted three separate analyses for each set of variables
(mother, father, and family) to better select the predictors to
include in the final models and to assure at least 10 par-
ticipants per predictor (Field 2009). In all three sets, ado-
lescent individual variables—sex and BMI—were included
in Step 1 given the strong relationships established between
females and DE and between high BMI and DE in existing
literature (e.g., Field et al. 2001). The first set included mothers’
BID and EDE-Q subscales; the second included fathers’
BID and EDE-Q subscales; and the last included parental
influences, perception of paternal relationship, of maternal
relationship, and of the family environment. Those predic-
tors which were significant (p \ .05) or near significant
(p \ .10) for each dependent variable of athletes or controls
were then culled from these preliminary regressions and
used in the final multivariate models.
Results
Descriptive Statistics and Differences Between
Athletes
and
Controls
Table 1 presents the descriptive statistics of all variables
and the results of mean comparisons between athletes and
controls (separated by sex) and between respective
parents.
Male athletes and controls showed no significant differ-
ences in any of the variables. Female athletes reported lower
BMI and higher levels of restraint and eating concern (two
subscales of EDE-Q) than did controls. Regarding adoles-
cents’ parents, there were no significant differences in any
variable between the mothers of athletes and controls,
regardless of gender, or between the fathers of female ath-
letes and the fathers of female controls. However, there were
some differences between fathers of male athletes versus
controls: the fathers of male athletes reported significantly
higher BMI than did those of controls as well as higher levels
of BID, shape concern and EDE-Q global score.
Correlations
Table 2 presents correlations between the variables
answered by adolescents, separated by athletes and con-
trols. In addition to the expected moderate-to-strong cor-
relations between BID and DE, where the correlations were
stronger for athletes than for controls, there were important
family-variable correlations to note. While there was no
significant correlation between parental influences and
BMI of athlete participants, there was a significant rela-
tionship between these variables for the controls. However,
parental influences were more strongly correlated to the
BID and DE of athletes than to those of controls. With
regard to athletes’ perception of family relationships, the
maternal relationship did not present significant correla-
tions with the BID or DE of either athletes or controls;
interestingly, the paternal relationship presented a weak but
significant correlation with the DE of both groups of ado-
lescents. Finally, the quality of family environment was
associated with parental influences reported by athletes but
not with those reported by the controls. However, the
reverse was true for DE such that the perception of family
environment significantly correlated with the DE of con-
trols only but not with athletes’ DE.
Parental influences reported by children (athletes or
controls) did not correlated with any of the parental vari-
ables indicative of BID or DE (Table 3). All significant
correlations of adolescents’ BID and DE with parental
variables were weak (r \ .30). Among the athletes, fathers’
eating concern alone was significantly correlated with
children’s DE. Among the controls, only maternal variables
were correlated with the BID and DE of their children—
shape concern, weight concern and EDE-Q global score—
with correlation with DE being stronger than with BID.
Body Image Dissatisfaction and Disordered Eating
Family Predictors
Tables 4 and 5 show the final regression models in both
samples, for BID and DE, respectively. Regarding athletes’
BID, sex, BMI and parental influences were significant pre-
dictors, accounting for 41 % of the variance; maternal
J Child Fam Stud (2013) 22:1082–1091 1085
123
variables were not significant predictors. For controls’ BID,
only sex and BMI were significant contributors, explaining
merely 26 % of the variance. For athletes’ DE, sex, BMI and
parental influences were the only predictors, accounting for
42 % of the variance. In the controls’ DE model, the variables
significant in the athletes’ model, as well as perceived family
environment, mothers’ eating concern and mothers’ weight
concern, in total explained 49 % of the variance in DE.
Family Characteristics of the Group with Clinical
Indication of DE
Taking into account the clinical indication of DE (EDE-Q
subscales or global score C3.5; Machado and Martins
2010), we compared the family variables’ scores of those
adolescents who score above the EDE-Q cut-off (n = 37;
17 athletes and 20 controls) with those of sub-cut-off
adolescents. Because these adolescents included only six
males, and given that the clinical indication of DE has not
proven to be associated with belonging to the athletes or
control group [v2(1) = 1.46, p = .265], we aggregated all
participants with EDE-Q scores above the clinical cut-off,
regardless of sex or study condition, and compared their
analyses with all other adolescents who scored below
EDE-Q cut-off.
Adolescents with a clinical indication of DE reported
significantly higher levels of parental influences (M = 1.64,
SD = 0.67 vs. M = 1.19, SD = 0.38; U = 1796.00,
Table 1 Descriptive statistics and mean comparisons (N = 227)
Range Girls (n = 142) Boys (n = 85)
Athletes
(n = 60)
Controls
(n = 82)
U p Athletes
(n = 25)
Controls
(n = 60)
U p
Adolescents
Age (years) 15.05 (2.40) 14.51 (1.81) 2193.50 – 16.08 (3.33) 14.68 (1.81) 596.00 –
BMI 18.66 (2.17) 19.79 (2.62) 1925.50 \.05 20.96 (3.21) 20.54 (3.42) 634.00 –
Parental influences 1 to 5 1.42 (0.59) 1.21 (0.41) 2068.50 – 1.16 (0.36) 1.18 (0.34) 641.50 –
Maternal relationship 1 to 5 4.63 (0.54) 4.66 (0.62) 2234.50 – 4.71 (0.47) 4.56 (0.74) 707.50 –
Paternal relationship 1 to 5 4.50 (0.65) 4.34 (0.88) 2232.00 – 4.64 (0.63) 4.37 (0.73) 628.50 –
Family environment 1 to 5 4.47 (0.60) 4.38 (0.72) 2356.50 – 4.50 (0.86) 4.24 (0.80) 712.50 –
Body image
dissatisfaction
-8 to 8 -0.55 (1.25) -0.61 (1.34) 2425.50 – -0.21 (0.89) -0.07 (1.17) 729.00 –
Restraint 0 to 7 1.33 (1.33) 0.78 (1.18) 1861.50 \.01 0.47 (0.67) 0.36 (0.83) 626.50 –
Shape concern 0 to 7 1.81 (1.65) 1.46 (1.36) 2365.50 – 0.67 (0.98) 0.77 (1.05) 729.50 –
Eating concern 0 to 7 0.97 (1.24) 0.46 (0.68) 2042.00 \.05 0.13 (0.23) 0.25 (0.48) 742.50 –
Weight concern 0 to 7 1.97 (1.80) 1.59 (1.56) 2264.50 – 0.45 (0.81) 0.59 (0.95) 743.50 –
EDE-Q global score 0 to 7 1.52 (1.41) 1.07 (1.09) 2135.50 – 0.43 (0.56) 0.49 (0.73) 721.50 –
Mothers
BMI 23.27 (3.68) 23.94 (3.84) 1893.50 – 24.78 (7.14) 24.53 (4.45) 525.50 –
Body image
dissatisfaction
-8 to 8 -1.50 (1.31) -1.14 (1.34) 2015.00 – -1.64 (2.02) -1.49 (1.40) 557.50 –
Restraint 0 to 7 0.54 (0.92) 0.73 (0.97) 2154.50 – 0.96 (1.60) 1.05 (1.43) 624.50 –
Shape concern 0 to 7 1.16 (1.24) 1.22 (1.12) 2044.50 – 1.25 (1.87) 1.24 (1.39) 667.00 –
Eating concern 0 to 7 0.26 (0.61) 0.22 (0.50) 2291.00 – 0.46 (1.04) 0.13 (0.37) 623.50 –
Weight concern 0 to 7 1.22 (1.32) 1.15 (1.14) 2004.50 – 1.30 (1.79) 1.26 (1.33) 666.00 –
EDE-Q global score 0 to 7 0.79 (0.89) 0.83 (0.78) 1909.00 – 0.99 (1.49) 0.92 (1.01) 657.50 –
Fathers
BMI 26.58 (3.83) 26.76 (3.38) 1705.50 – 28.28 (4.38) 26.80 (4.12) 339.50 \.05
Body image
dissatisfaction
-8 to 8 -1.24 (0.94) -0.83 (1.11) 1654.00 – -1.50 (1.09) -0.93 (0.91) 362.00 \.05
Restraint 0 to 7 0.67 (0.98) 0.61 (1.17) 1844.50 – 0.54 (1.02) 0.37 (0.75) 462.00 –
Shape concern 0 to 7 1.06 (1.25) 0.71 (1.13) 1676.00 – 0.96 (0.94) 0.58 (0.97) 377.50 \.05
Eating concern 0 to 7 0.24 (0.43) 0.23 (0.65) 1932.00 – 0.10 (0.28) 0.07 (0.21) 526.00 –
Weight concern 0 to 7 1.09 (1.40) 0.89 (1.41) 1841.00 – 0.93 (0.94) 0.67 (1.04) 381.00 –
EDE-Q global score 0 to 7 0.76 (0.86) 0.61 (0.94) 1733.00 – 0.63 (0.53) 0.42 (0.65) 305.00 \.01
1086 J Child Fam Stud (2013) 22:1082–1091
123
p \ .001), perceived lower quality in their paternal rela-
tionship (M = 3.86, SD = 0.99 vs. M = 4.51, SD = 0.68;
U = 2357.00, p \ .01), lower quality in their maternal
relationship (M = 4.14, SD = 0.94 vs. M = 4.70, SD =
0.52; U = 2583.50, p \ .01) and lower quality in family
environment (M = 3.82, SD = 1.01 vs. M = 4.44,
Table 2 Spearman correlations between adolescent variables, for athletes and controls
Athletes (n = 85) Controls (n = 142)
1 2 3 4 5 6 7 8
Sex
a
– -.17* .08 .03 -.07 .10 -.13 .37**
BMI -.23* – .28** -.03 -.12 -.24** -.48** .24**
Parental influences .08 .00 – .52** -.14 -.13 -.22* .37**
Maternal relationship -.01 -.22 -.12 – .51** .52** -.01 -.14
Paternal relationship -.14 -.17 -.20 .68** – .63** .07 -.25**
Family environment .03 -.30** -.24* .62** .55** – .10 -.25**
Body image dissatisfaction -.18 -.50** -.24* .07 .19 .14 – -.44**
Disordered eating .35** .26* .45** -.13 -.25* -.21 -.69** –
Athletes’ correlations appear below the diagonal, and controls’ correlations appear above the diagonal;
a
sex of adolescent (boys = 0, girls = 1);
** p \ .01; * p \ .05
Table 3 Spearman correlations between parental (BID and EDE-Q subscales) and athletes and controls’ variables (parental influences, BID and
DE)
Variables Athletes (n = 85) Controls (n = 142)
Parental influences BID DE Parental influences BID DE
Mother’s BID .07 .10 -.06 -.07 .04 -.04
Mother’s restraint .09 -.03 -.03 .13 -.04 .09
Mother’s shape concern .06 .02 -.01 .08 -.19* .27**
Mother’s eating concern .01 .10 -.02 .12 -.02 .13
Mother’s weight concern .14 -.04 .05 .05 -.20* .26*
Mother’s EDE-Q global score .05 .01 -.00 .10 -.17* .29**
Father’s BID -.03 .22 -.07 -.09 .03 -.02
Father’s restraint -.07 -.21 .20 .14 -.10 .12
Father’s shape concern -.01 -.20 .12 .09 .03 .11
Father’s eating concern -.00 -.15 .25* -.04 .03 .09
Father’s weight concern -.05 -.20 .16 -.03 .02 .09
Father’s EDE-Q global score -.06 -.23 .17 .02 -.02 .11
BID body image dissatisfaction, DE disordered eating; * p \ .05; ** p \ .01
Table 4 Summary of multiple linear regression analyses for variables predicting athletes’ and controls’ body image dissatisfaction
Variable Athletes Controls
B SE B b B SE B b
Sex
a
-0.86 0.27 -.33** -0.57 0.21 -.22**
BMI -0.28 0.05 -.61*** -0.18 0.04 -.41***
Parental influences -0.44 0.20 -.22* -0.24 0.24 -.08
Mother’ body image dissatisfaction -0.03 0.10 -.03 -0.15 0.09 -.17
Mother’ restraint -0.27 0.14 -.25 0.04 0.11 .04
Mother’ weight concern 0.18 0.12 .21 -0.21 0.12 -.20
R
2
.41 .26
F 7.64*** 7.01***
a
Sex of adolescent (boys = 0, girls = 1); *** p \ .001; ** p \ .01; * p \ .05
J Child Fam Stud (2013) 22:1082–1091 1087
123
SD = 0.64; U = 2664.00, p \ .01). Additionally, the par-
ents of these adolescents revealed some differences on their
own EDE-Q scores when compared with the parents of the
adolescents below clinical levels of DE symptoms. Mothers
were more concerned about their own body shape
(M = 1.65, SD = 1.19 vs. M = 1.17, SD = 1.29; U =
2368.50, p \ .05) and weight (M = 1.53, SD = 1.23 vs.
M = 1.15, SD = 1.28; U = 2606.00, p \ .05), while
fathers had higher levels of restraint (M = 0.99, SD = 1.27
vs. M = 0.48, SD = 0.95; U = 1883.00, p \ .01), weight
concern (M = 1.48, SD = 1.70 vs. M = 0.75, SD = 1.16;
U = 1736.50, p \ .05) and EDE-Q global score (M = 0.95,
SD = 1.05 vs. M = 0.52, SD = 0.76; U = 1655.00,
p \ .05).
Discussion
Our study sought to focus on the influences of several
family variables—particularly related to the mothers and
fathers of adolescents—in the body image dissatisfaction
and disordered eating of elite aesthetic athletes, compared
with a control group of non-athlete adolescents and their
parents.
Related to the first objective of our study, adolescents’
individual variables showed the expected differences
according to the literature (e.g., Byrne and McLean 2002),
with female athletes presenting lower BMI and higher
levels of two indicators of disordered eating (restraint and
eating concern) compared with the controls. However, we
also expected to find global levels of disordered eating that
were significantly higher, as demonstrated in a previous
study in which these same adolescents participated (Fran-
cisco et al. 2012). Because the mean values of disordered
eating are lower than expected in this study, we propose
two possible explanations for this fact: (1) adolescents with
higher levels of disordered eating may have been less ready
to seek cooperation from parents to participate in the study
because the subject of the investigation could trigger
weight- and/or eating-related conversations with their
parents (a behavior that the literature shows people with
disordered eating generally avoid); or (2) parents of ado-
lescents with higher levels of disordered eating may have
refused to participate, possibly because they also had
unhealthy eating behaviors and attitudes. However, the
absence of significant differences in body image dissatis-
faction and disordered eating indicators of the mothers of
participants of either gender and the fathers of female
participants do not support the results of the only known
study comparing aesthetic athletes with the controls
(Klump et al. 2001). Given that different measures were
used by Klump et al. (2001), future studies should be
conducted to clarify whether there are significant differ-
ences between parents of elite aesthetic athletes and those
of adolescents in general. For variables concerning family
relationships, there were no significant differences between
athletes and controls (either for boys or girls). Thus, we can
assume that the quality of family environment and parental
relationships, as well as parental influences on weight and
body image, are perceived similarly by athlete and control
adolescents.
Nevertheless, in the context of our second objective for
this study, we found different associations between family
variables and body image dissatisfaction and disordered
eating for athletes than we did for the controls. The sig-
nificant correlation between parental influences and BMI
among controls, but not in the athletes, reinforces the idea
that the critical comments received by elite athletes do not
depend on their BMI, as well as social influence in general
(Francisco et al. 2012). Instead, the critical comments
received by elite aesthetic athletes are an element of the
aesthetic sports subculture, and the parents also seem to
follow this same subculture. The strength of the correla-
tions between parental influences and body image dissat-
isfaction and disordered eating in athletes (more so than for
controls) points to the importance of studying the family
Table 5 Summary of multiple linear regression analyses for variables predicting athletes’ and controls’ disordered eating
Variable Athletes Controls
B SE B b B SE B b
Sex
a
1.07 0.28 .38*** 0.82 0.14 .38***
BMI 0.17 0.05 .34** 0.06 0.02 .16*
Parental influences 1.01 0.22 .43*** 0.97 0.16 .42***
Family environment -0.13 0.20 -.07 -0.25 0.09 -.18**
Mother’ eating concern -0.05 0.26 -.02 -0.53 0.18 -.24**
Mother’ weight concern -0.05 0.12 -.05 0.26 0.07 .31***
R
2
.42 .49
F 7.97*** 20.57***
a
Sex of adolescent (boys = 0, girls = 1); *** p \ .001; ** p \ .01; * p \ .05
1088 J Child Fam Stud (2013) 22:1082–1091
123
contexts of aesthetic elite athletes, who are already a group
at increased risk for the development of body image and
eating disturbances. Moreover, given the absence of sig-
nificant correlations between parental influences and par-
ents’ body image dissatisfaction or disordered eating, we
suggest that perhaps parents are not motivated by their own
personal concerns. Rather, we believe that parental influ-
ences may be a reflection of socio-cultural pressures: par-
ents are simply a conduit for reinforcing thinness as the
standard of beauty.
To address to our third objective, we examined multiple
regression models for both athletes and the controls. Dif-
ferent family factors predicted body image dissatisfaction
and disordered eating for athletes and the controls. As
expected, based on existing literature (e.g., Field et al.
2001; Francisco et al. 2012), adolescents’ sex and BMI
were significant predictors of either body image dissatis-
faction or disordered eating for both athletes and the con-
trols. In addition to these two individual predictors,
parental influences emerged as the only family variable that
predicted athletes’ body image dissatisfaction and disor-
dered eating, especially for disordered eating. We believe it
is necessary to alert parents in the elite aesthetic sports
community to the influence of their comments and values
on their athlete children because these comments can
strengthen the concerns of adolescents and others in the
social contexts of the adolescent’s sport (i.e., peers and
coaches). Ideally, parents would be integrated into pre-
ventive actions within the context and communities of
aesthetic elite sports. It is essential that the family system
provides conditions that balance the demands of thinness
within the community of these sports. In relation to control
adolescents, parental influences were not predictive of
body image dissatisfaction or any other family variable.
However, for disordered eating in the control group, a
larger number of family variables emerged as predictors.
Apart from parental influences, consistent with Field et al.
study (2001), eating and weight concern of mothers–con-
firming the influence of maternal modeling pointed by
other authors (e.g., Pike and Rodin 1991)–and the negative
perception of the quality of family environment proved to
be important predictors, as opposed to the quality of the
specific relationship with each parent. Thus, family envi-
ronment should be taken into account in the future to
explore the specific features that make this variable a
predictor of disordered or healthy eating behaviors.
Finally, our fourth objective has led us to investigate the
differences on family variables between adolescents who
scored above and below the EDE-Q cut-off. Our results
agree with the literature that investigates family charac-
teristics associated with disordered eating: adolescents at
higher clinical risk did perceive lower quality in their
relationships with both parents, as well as within the family
environment overall (Archibald et al. 1999; Blackmer et al.
2011; Crespo et al. 2010), and their parents endorsed more
weight teasing and concern with their child’s thinness (Ata
et al. 2007; Smolak et al. 1999). In addition, the differences
between in parent–child relationships coincides with the
findings of Pike and Rodin (1991), who found associations
between mothers’ and daughters’ disordered eating
behaviors, but not between those of father and daughter
(Keel et al. 1997; Yanez et al. 2007). Our data, when
considered in the context of existing literature, suggest the
need to continue studying fathers and their eating behavior,
a theme often neglected in other studies.
In conclusion, as was found by Wertheim et al. (2002),
our data seem to indicate that parental influences have
greater influence when it presents in the form of parent
concern with child thinness and weight teasing rather than
as parental modeling of dieting or body concerns, espe-
cially among athletes. Exposure to many other social
models of eating behavior—from peers, television and, in
the specific case of athletes, coaches—can diminish the
contribution of parents. However, among adolescents in the
general population, maternal modeling still seems to have a
major impact on disordered eating. This finding should be
taken into account in preventive actions, particularly
because healthy food models can also predict healthy eat-
ing behaviors in adolescents.
The present study has several limitations that should be
taken into consideration when interpreting our results.
First, the relatively small sample size of adolescent athletes
presents challenges, especially for carrying out multiple
regressions. These regressions are potentially unstable and
thus preliminary, offered as indicators for future research,
which should also seek to test these models in different
samples of male and female athletes. The cross-sectional
design represents another limitation because it does not
allow for causal inferences to be made with regard to the
influence of family variables in the development of ado-
lescents’ body image dissatisfaction and disordered eating.
Longitudinal studies are needed for a proper exploration of
this influence. Despite these limitations, this study has
strengths and makes important contributions to the litera-
ture. To our knowledge, it is the first time a characteriza-
tion of the family influences on body image dissatisfaction
and disordered eating has been conducted with both female
and male aesthetic athletes, also including both mothers
and fathers. Thus, being considered an exploratory study,
this study has enabled the identification of several specific
and relevant aspects of elite aesthetic athletes’ families to
be considered more rigorously in future studies.
Acknowledgments This work was funded by a Ph.D. Grant awar-
ded to the first author by the Fundação para a Ciência e a Tecnologia,
Portugal (SFRH/BD/27472/2006). The authors would like to thank all
J Child Fam Stud (2013) 22:1082–1091 1089
123
the adolescents, parents and heads of school who participated in the
study.
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Abstract
Introduction
Method
Participants
Measures
Measures Completed by Adolescents
McKnight Risk Factor Survey-IV (MRFS-IV; The McKnight Investigators 2003)
Perception of Parent–Child Relationships Quality and of Family Environment
Measures Completed by Both Adolescents and Parents
Contour Drawing Rating Scale (CDRS, Thompson and Gray 1995)
Eating Disorder Examination-Questionnaire (EDE-Q, Fairburn and Beglin 1994)
Procedure
Statistical Analyses
Results
Descriptive Statistics and Differences Between Athletes and Controls
Correlations
Body Image Dissatisfaction and Disordered Eating Family Predictors
Family Characteristics of the Group with Clinical Indication of DE
Discussion
Acknowledgments
References
