Pakistan Journal of Professional Psychology: Research and Practice Vol. 12, No. 2, 2021

The Effectiveness of Cognitive Behavioral Therapy for Managing Body Image

Dissatisfaction

*Iqra Ramzan

Iqra University North Campus, Karachi, Pakistan

Barerah Siddiqui

behavioral therapy (CBT), adapted from CBT manual for depression (Naee, & Ayub, 2013),

were conducted in an individual setting on a weekly basis. The results suggested a significant

contribution of CBT in decreasing the level of dissatisfaction related to body image. The scores

of pre and post testing (p <.05) of experimental group verified the efficacy of CBT in treating

dissatisfaction associated with body image. Thus, it can be concluded that CBT is effective in

treating dissatisfaction related to the body image among adolescents and adults. The study helped

in drawing attention towards treatment of body image dissatisfaction (BID) in the Pakistani

population and contributed to the empirical basis of effectiveness of CBT in managing body

image anxiety.

Keywords: body image dissatisfaction, CBT, adolescents, adults

adolescents even before the age of 8 years (Heron et al., 2013), which results in the desire to

have thin bodies and to diet (Damiano et al., 2015). Body image dissatisfaction (BID) is defined

as an individual’s negative feelings and perception about their body and is affected by factors

such as body size, appearance, weight, and culture (Peat et al., 2008; Phillips & de Man, 2010).

These negative effects have a direct impact on individuals’ living styles, physical and

psychological health.

The BID leads individuals to form negative beliefs about the self, schemas related to

body image and to engage in maladaptive behavior i.e avoid eating and social gatherings

(Ferreiro et al., 2014). Individual with BID label their selves as incompetent as they perceive

their self as unattractive. The BID is more about building a belief that a specific body part like

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Maxwell & Cole, 2012). Body image dissatisfaction is considered as a maintaining and

predicting factor of disturbed eating behaviors such as starvation, binge eating, using laxatives

(Fairburn et al., 2003; Midlarsky & Nitzburg, 2008), and purging, affecting physical and mental

health (Stice et al., 1998).

Body image issues appear to be significant in both men and women (Ferraro et al., 2008;

Pruis & Janowsky, 2010; Slevec & Tiggemann, 2011). The reasons for BID in both the genders

differ. Approximately 20 % and 40 % of men reported dissatisfaction about their overall physical

appearance, muscle tone and size, and weight (Frederick et al., 2014). Men feel that they can be

judged on the basis of appearance and compare their appearance to others at social events

(Frederick et al., 2014). On the other hand, women personalize body shame more, and are

lessened by factors such as shame and being silent about their BID (Brennan et al., 2010; Burlew

& Shurts, 2013). Therefore, the treatment for BID is needed for both (McCabe & Ricciardelli,

2004).

BID also results in negative consequences in Asian countries as well as Western

countries. It has been reported that 60.1 % students have BID in Malaysia (Latiff et al., 2018)

and have greater association with disturbed eating and low self-esteem (Franko & Striegel-

Moore, 2002). Researchers have found that Pakistani and Indian women have a high rate of

dissatisfaction related to their body image, size and shape (Mumford & Choudry, 2000). A study

conducted in Pakistan revealed that women showed greater dissatisfaction of body shape and

size (Najam & Ashfaq, 2012).

BID appears to affect the lives of individuals biologically as well as psychologically,

such as engagement in unhealthy eating, using steroids or other medicines, aggression, irritability

and mood disorders, low self-esteem etc. It also affects relationships of people because of their

negative automatic thoughts (NAT’s) and negative self-schemas related to body image (Butters

& Cash, 1987). Cultural standards play an important role in body image; in society being thin,

and fair is considered as a beauty standard in women, whereas standards for men are muscularity

and tall height (Greenberg, 2009). These standards are learned through comments from family,

friends and media. These societal criteria make individuals feel pressured and they suffer from

psychological distress. The BID causes disturbance and anxiety in daily life. Therefore,

treatment is needed. If it is not treated on time, then it may lead to body dysmorphic disorder, or

COGNITIVE BEHAVIORAL THERAPY AND BODY IMAGE DISSATISFACTION 59

how to handle and manage these psychological problems effectively and develop rational

thoughts. This research will also help in understanding the context and intention of these

messages and acting in a healthy way by testing reality.

comments from family, peers, and media. As Williamson’s model of body image explains, it is

internalization of socio-culturally defined ideals which leads an individual to build errors in

cognition. This later leads to anxiety and other psychological problems (Williamson et al., 2004).

A person in turn builds an appearance related self-schema because of the negative emotions

created through cognitive errors or biases. The role of messages from family, peers and media

impacts an individual’s thinking pattern and results in creating negative and unrealistic ideals for

BID. Another leading factor for NAT’s is social comparison with others and sometimes these

are portrayed by the media and people consider them to be ideals. These factors cause

psychological distress and negative self-evaluation. To solve this psychological distress,

cognitive and behavioral interventions were used such as psycho-education, thought challenging,

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Objectives of the Study

giving CBT as compared to control group.

Hypothesis of the Study

adolescents and adults.

compared to the control group.

COGNITIVE BEHAVIORAL THERAPY AND BODY IMAGE DISSATISFACTION 61

1983). The test re-test reliability of scale was .94 for men and .89 for women which is

significantly high.

Cognitive Behavioral Therapy (CBT) Manual (Naeem & Ayub, 2013)

The session plan was adapted from the manual of CBT for depression by Naeem and

breathing techniques, thought diary, challenging negative automatic thoughts, psycho-education

on cognitive errors, if-then questioning, and cost benefit analysis. These were the major

techniques which were used to manage body image dissatisfaction as it was reported from the

literature that cognitions play important role in BID.

Prior to the implementation of the study, permission was taken from the supervisor of

Bahria University, Karachi and authors of measures. After that the informed consent form and

demographic form were given to each participant and they were told about the confidentiality

procedures verbally as well as their written consent for participation in the study was taken. Then

a pre-test was conducted by using BDS. After taking the pre-test score individuals who fell under

the criteria were recruited and divided into two groups randomly: An experimental group and a

waiting list control group. The experimental group was offered individual therapy sessions

following a structured manual of CBT that was translated. The total program comprised eight

sessions, once a week for 50 minutes. In the last session, a post-test was carried out for the

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Session 5. The aim of this session was to understand the concept of ideal and real self.

The concept of social comparison and its impact on self-evaluation was discussed. Technique of

cost-benefit analysis was introduced and practiced on negative self-evaluation. Thought

reconstruction was taught.

including challenging the media’s portrayal of the ideals, and appearance assumptions was done

through reflective questioning. Relaxation techniques such as deep breathing were practiced.

healthy diet and exercise.

COGNITIVE BEHAVIORAL THERAPY AND BODY IMAGE DISSATISFACTION 63

Table 2

group as well as post-test scores. For post-test p < .05, which shows significant difference in

levels of dissatisfaction related to body image after giving CBT as an intervention to

experimental group. The mean values of pre-test of experimental and control group (pre: M =

47.25; post: M = 54.8) indicates that the participants of both the groups had high levels of BID

on self-reported questionnaire, while in the post-test scores of experimental and control group

there is a significant difference. Thus, this verifies the hypothesis that there is a significant effect

of CBT in managing body image dissatisfaction.

Discussion

In the light of past researches, it was hypothesized that the CBT will have an effect on

BID. Previous researches have provided evidence for the efficacy of CBT with body image

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Most of previous researches concluded that BID is normative among women (Lewis &

Devaraj, 2010; McLaren & Kuh, 2004; Tiggemann, 2001). The present study targeted both the

genders as some researches provided evidence for the prevalence of BID in men as well (Hardit

& Hannum, 2012; Salk & Engeln-Maddox, 2012).The present study showed that CBT is an

effective treatment in treating BID as the Table 3 shows post intervention p< .05 (post: p=0.003).

This provides evidence for the effectiveness of CBT in treating BID among Pakistani population.

The second hypothesis assumed that there is a difference between the results of pre-test

and post-test in experimental group. The paired sample t-test analysis showed the significant

differences in the pre-intervention (M = 47.25, SD = 16.18) and post-intervention (M = 20.62; SD

= 10.80) scores of experimental group, t(7) = 7.61, p < .05. Hence, providing the evidence for

and waiting list control group among early adolescents and adults.

From the analysis it is also found that all the participants experience discrepancy between

their ideal self-image and real self-image. They all reported that because of this they get involved

in maladaptive behaviors such as excessive gyming, disordered eating, taking pills for body

weight, height, injecting whitening medicines etc. as they feel anxious about their body image.

Thus, consistent with the theory of self-discrepancy, an individual who faces discrepancy in ideal

and real body image tends to have low levels of body satisfaction, which leads them to get

involved in appearance related behaviors such as disordered eating and cosmetic surgeries

(Vartanian, 2012).

Informal assessment and qualitative analysis showed that individuals before the

individuals with higher levels of body dissatisfaction had low self-esteem as they perceived

themselves as not capable of doing things and achieving satisfactory relationships. These

observations match the previous studies on figuring out the effects of body image dissatisfaction.

Among these factors most common are: low self-esteem (Stice & Shaw, 2002; Thompson et al.,

1999), depression (Stice & Bearman, 2001) and overall poor quality of life (Franko & Striegel-

Moore, 2002; Thompson et al., 1999). These individuals also mentioned that they felt depressed

whenever they felt a discrepancy between their ideal and real self, which is also consistent with

the results of previous research. All these factors lead them to build negative coping in their

selves which affects their psychological, biological and social lives.

Messages and comments about body image which an individual receives from family and

COGNITIVE BEHAVIORAL THERAPY AND BODY IMAGE DISSATISFACTION 65

comparison tend to have an increased level of dissatisfaction related to their body, developing

maladaptive eating patterns (Khan et al., 2017). Media also plays a vital role in developing ideal

body image and social comparison with models. Individuals who idealized models for their body

image, tend to face more dissatisfaction as it is very difficult for them to maintain their body

image and also remaining physically healthy (Green & Ohrt, 2013). Messages that come from

the media are also a strong contributor in developing schema of thinness and BID (Cafri et al.,

2005).

All participants of the present study reported that their families and peers always have

commented on their body image which had greater impact on their BID. They felt pressured and

anxious whenever they commented on their body image, regardless of their intention. Most of

dissatisfaction, creating realistic ideals and developing healthy behavior (i.e. exercises, healthy

eating habits, and relaxation techniques). Hence, verifying the hypothesis that there was an effect

of CBT in managing BID among adolescents and adults.

The present study aimed to investigate the efficacy of cognitive behavioral treatment for

body image dissatisfaction among adolescents and adults, in an individual setting. The findings

showed a statistically significant difference in the scores of pre and post-test of experimental

group and also between the post-test scores of experimental and control groups. The findings

indicated that the level of dissatisfaction was significantly less within the experimental group

after intervention, as compared to the waiting list control group, hence supporting the second

hypothesis. Moreover, it can also be concluded that CBT decreases the severity levels of BID

among adolescents and adults of the Pakistan. Thus, it may be concluded that the present study

supported the efficacy of CBT for treating BID.

Implications of the Study

This study highlighted that adolescents and adults can be easily taught how they can alter

their negative thoughts related to body and increase their satisfaction of body image by building

more healthy behaviors. These CBT based techniques can be utilized by fresh psychology

graduates after required training.

Limitations and Recommendations

In the light of the present study on the efficacy of CBT in managing BID, a few

limitations and recommendations are suggested. The present study targeted the limited range of

age of men and women. It is suggested for future research to target other age groups as well.