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Body Dysmorphic Disorder Techniques for Treating Obesessions with Body Perfection
Body Dysmorphic Disorder: Diagnosis & Treatment - 10 CEUs

Section 25
Integrative Group Psychotherapy for BDD, Part I

CEU Question 25 | CEU Answer Booklet | Table of Contents | Body Dysmorphia
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

While the medical community describes obesity according to body mass index, to further understand the psychiatric implications of obesity and disordered eating, one must first understand the language of the field. Obesity is classified into constitutional and symptomatic obesity (developmental and childhood onset), and reactive obesity (adult onset).

Constitutional obesity starts in childhood, frequently in infancy, and is often familial. These youngsters usually have good social, school, and emotional adjustment. They usually do not eat more than slim people, although they may be less active. It is postulated that constitutionally obese individuals may have a high physiological set point to which the body returns even after dieting, and that attempts to lose weight may result in a chronic state of starvation. Symptomatic obesity refers to developmental or childhood onset of obesity associated with emotional problems that begin in childhood. Reactive obesity is associated with eating problems that begin in reaction to a major trauma in adulthood.

Body self refers to the full range of kinesthetic experiences on the body's surface and in its interior, and the body's functions. "The developments of a body self can be conceptualized as a continuum of three stages, the first of which is the early psychic experience of the body. The second stage is the early awareness of a body image, with an integration of inner and outer experience. This process forms body surface boundaries and internal state definition. The final stage is the integration of the body self as a container of the psychological self, the point at which the two merge to form a cohesive sense of identity".

Body image (BI) refers to the physical, emotional, and interpersonal view of one's body--the inner mental picture and sum of emotional attitudes towards it. This picture represents the physical perimeter of one's body as a whole, as well as the size, shape, and spatial relationships of its parts. The emotional feelings and attitudes are the major components of body image and can influence the accuracy of the inner mental blueprint. The linkage between body and mind takes shape during the formative, developmental stages of the individual. Body image disturbance (BID) is the over- or underestimation of the body's actual size and shape, coupled with derogatory attitudes of the self. Derogatory attitudes consist of shame and self-loathing about girth, real or fantasized. These attitudes develop from continuous negative attitudes and criticism towards the child about appearance. The parent, in essence, rejects the child as he or she is. The child becomes the container for which the parent projects his or her own negative unresolved issues. This empathic misalignment between parent and child can give rise to developmental deficits and body-image and self-image pathology as seen in childhood and juvenile onset of obesity. Cultural influences have an impact, but less so than family of origin. The body-image problems of adult onset obesity arise out of having a "thin memory". Such patients retained a "normal" weight in childhood while traversing developmental milestones and then gained weight in adulthood. Their self perception is thin, not fat, what I call the "fat, thin" people. Conversely, "thin, fat people," are those who were fat as children and who got stuck developmentally then lost weight as adults and continue to see themselves as fat. Bruch refers to them as carrying an image of their former size like a "phantom" within them. Bruch also refers to the "thin fat people" in her population of anorexics, who see themselves as grotesquely fat. Their concept of body image is fixed in childhood, thus their view of their BI today, as adults, remains as if it were then, in their childhood.

Body-oriented therapy (BOT) includes all forms of psychotherapy that focus on the body to improve psychic functioning. In this approach, patients are faced with primarily nonverbal experiences, which can be discussed later in treatment. BOT is usually connected to existing psychotherapeutic schools of thought. BOT has been applied to eating disordered patients under different names: body-image groups, body-image therapy, body-movement therapy, dance-movement therapy, physiotherapy, and psychomotor therapy.

Body experience refers to the neurophysiological aspect--body scheme, body orientation, body size estimation, body knowledge--as well as to the psychologic phenomenological aspect--body image, body awareness, body boundary, and body attitude. Body experience comprises all individual and social experiences: the affective and the cognitive, the conscious and the subconscious. Thus the concept of body experience is multi-dimensional.

Development Of Body Image And Body-Image Disturbances
Nonpathological development of body image is well described in Krueger's work. He suggests that: "psychotherapy and psychoanalysis focuses nearly exclusively on the psychological self without sufficient regard for the body self as the container and foundation of the psychological self. The body image and sensory awareness/integration of those with eating disorders has been subjected to the same process of developmental arrest as their psyches". He further observes: "Their body images were disrupted, blurred, distorted, incomplete, or infantile, and often fluctuated with emotional state. Those with severe narcissistic and borderline pathology may not experience the distinctness of their bodies or their body boundaries. Lacking this consistent and accurate internal image of their bodies and sense of self, such patients necessarily rely on other people and external feedback and referents to mirror their worth and adequacy. Object and internal image constancy are missing". The psychodynamic literature suggests that children who have eating issues, who encounter negative input from family and others that extends through adolescence, are susceptible to developing a body-image disturbance. Bruch wrote about the families that produce persons with eating disorders and body image disturbances. The roots of difficulty lie in the disturbed relationship with mother at a very early preverbal level. The type of mothering experienced by these patients is that they were used as an object to fulfill the needs of one or both parents and to compensate for failure and frustration in the parent's own life. "Since feeding is often a response to the parent's emotional needs rather than to the child's hunger, these patients grow up confused about their own body urges and are unable to distinguish hunger from anxiety or other emotional states. The pathological bond between parent and child results in feelings of helplessness and inadequacy, resulting in a deficient sense of separateness". The Kaplans and later Herzog support this theory.

Winnicott eloquently describes the elements of difficulties with individuation from an object relation point of view. Wilson suggests that the selection of a child for the development of obesity occurs by process of parental neglect rather than over concern as in the anorexia and bulimia nervosa. Conversely, the cognitive behavioral literature depicts that teasing is the culprit for instigating BID and suggests that the treatment for negative BI is the cognitive desensitization and restructuring of thinking beginning with the focus of restructuring negative self-talk. Krueger's work provides the missing theoretical explanation for the development of distorted body image. He explains that those at risk have early developmental pathological sequelae, which fall into three groups. Although not mutually exclusive, the types of interactions can be described as: 1. parental over intrusiveness; over stimulation; 2. parental empathic unavailability; and 3. parental inconsistency or selectivity of response. Thus a more sophisticated understanding of the development of body image disturbances is laid out. Although teasing can be a contributing factor, BID mostly stems from developmental deficits.

The Integrated Group Psychotherapy Model --An Overview
The Integrated Model for Group Psychotherapy is an integrated clinical approach that makes use of elements of psychoanalytic and psychodynamic theory, object relations theory, self psychology, gestalt therapy, attachment theories, experiential, body oriented and sensory motor therapies within the context of group psychotherapy. The group creates a holding environment where patients can deconstruct the evolution of their body image and distorted view of self and eventually reconstruct a healthier internal model. The long-range goal of the Group is Yalom's transfer of learning function, i.e., that this healthier model will be integrated into the patients' internal schema/structure enabling them to transfer it to their life outside of the group.

The Group Model: Introducing Movement
The Integrated Group Psychotherapy Model explored integration of mind and body through the use of movement. Movement, which is central in the development of body image had been neglected in the treatment of body-image problems. Selected movements of T'ai Chi were modified and selected for this population. T'ai Chi was chosen since it centers awareness of self within the body. T'ai Chi, an ancient form of Chinese movement art, is used as a nonintrusive and nonthreatening form of body-oriented therapy because it allows patients to have a body experience and accurate mirroring, i.e., using movement to experience inner and outer body images that are necessary for body-image development. My colleague, who co-led this group, is a trained dance performer, a T'ai Chi instructor, and a certified teacher of the Alexander technique. Incorporated into the group process, was a tactile exercise called "body sculpting" which made use of patient's guided self-touch. In this process, the therapist, through verbal guidance, mimics a parent "holding" a child positively. The patient, through self-touch, reexplores his or her body boundaries. The mirroring comes through the transference with the therapist and from the modified movements of the T'ai Chi instructor. The sculpting exercise grew out of the literature on childhood development in which body movement and touch have been shown to shape body image.

Treatment And The Use Of Movement In Body Image Literature
Schilder underscores the importance of motility in his 1935 study of body image. "We would not know much about our bodies unless we moved them. Sensations stemming from multiple perceptual and muscular feedback are integrated into a dynamically developing body image, thus motility plays an essential role, not only in defining the boundaries of the self, but in differentiating one's self from the total perceptual environment." The inactivity so characteristic of obese people thus appears to be related to their often disturbed body concept. There is little indication in the obesity literature, however, that body awareness, movement, and tactile techniques are used in the treatment of obese adults. Overweight patients often have difficulty moving. Even walking can be a chore. Full-length mirrors are avoided. In addition to avoidance and denial, obese adults reported that they had anesthetized their bodies. This was especially true in the sexual arena. Dissociation was central to their pathology. It became apparent that perception of one's body image could not change from merely talk therapy. It seemed that incorporating movement into the therapeutic work was a natural progression in treatment. Current work in trauma helps us better understand the mind-body connection. Krueger wrote about treatment through movement with anorexics and bulimics. He suggested that there is no "authentic" movement for anorexics and bulimics. Because of the missed early experience of accurate mirroring as children, these patients have not experienced any internally directed autonomous communication of feeling. Their bodies are not seen as vehicles for their own expression, but rather as mirrors for the feelings of others. His model of treatment focuses on accurate mirroring, utilizing dance movement, designed to integrate the mind and body as this basic body awareness has never been completely established. The dance movement parallels a normal developmental sequence.
- Weiss, Fran, Group Psychotherapy with Obese Disordered-Eating Adults with Body-Image Disturbances: An Integrated Model, American Journal of Psychotherapy, 00029564, 2004, Vol. 58, Issue 3
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #11
The preceding section contained information regarding integrative group psychotherapy for BDD.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 25
According to Weiss, why is Tai’Chi useful in group psychotherapy for BDD? Record the letter of the correct answer the CEU Answer Bo