‘If I lose another 7lbs, I might be good enough,’ said Phillipa.

Like many people, Phillipa subscribed to the illusion that changing her body would put her in control of her life. The efforts she made to change her body gave her temporary relief from painful emotions. She could distract herself by focusing on narrow and structured tasks to alter her body shape that felt more manageable than addressing the complexities of relationships.

Phillipa felt that for most of her life she was unable to identify when she was hungry or full and had overridden communications from her body when she felt tired or physically weak. She described having the illusion that ‘she had no body but lived behind her eyes’. Her mother had used food as a reward or comforter and she believed that this had made her confused about her bodily sensations and wary of trusting them.

She could acknowledge that she had projected her difficulties in interpersonal relationships onto her body, and feared that once her ‘perfect slim ideal’ was achieved there would be no more room for problems. This paradoxically meant that she had an investment in perceiving herself as overweight.

Our body image is crucial in the development of our concept of self and contributes to how we experience all our relationships. We form a picture in our own mind of how the body looks, and we have strong feelings and attitudes towards this picture. These powerfully affect the ways in which we behave and relate to others. A significant feature of any eating disorder is having a self-evaluation that is very reliant on one’s perception of body weight and shape. No substantial or lasting recovery is achieved without addressing the body image disturbance.

The body image group

This group was part of an eating disorder recovery programme available to those clients who had completed other aspects of the treatment and whose eating disorder had stabilised. They had therefore made a secure attachment to the unit, had some confidence in our treatment and had learnt to cope with some difficult feelings.

The initial goal of therapy was to identify the attitudes that clients had towards their bodies and to decode what feelings, thoughts and interpersonal struggles these had come to represent. The second goal of treatment was to develop alternative beliefs about themselves and their bodies. Given that definitions of body image include perceptual, cognitive, emotional, behavioural and interpersonal dimensions, it seemed that a mulitimodal therapeutic approach would be appropriate. From the literature on treatment of body-image disturbance we gleaned a range of cognitive tools: diary keeping, desensitisation, visual imagery and guided fantasy to uncover long established negative beliefs. From the arts therapies we came upon expressive and directive techniques such as body tracing, self-portraits and mask making used in conjunction with verbal psychotherapy interventions.

Using the above information we drafted a 12-week body image group programme utilising a range of techniques. Over time, we found strong resistance to desensitisation, and discovered that mindfulness was more palatable for clients than relaxation. We evolved our own subjects for image making and found that as the groups developed their own life, members preferred to depict their internal worlds without direction from the therapists.

The pre-group

Prospective group members were invited to attend an experiential ‘pre-group’, enabling them to have a ‘live’ experience of using possibly less familiar techniques of mindfulness, movement, guided imagery and art materials.

In the pre-group, the women used art materials to depict ‘thin’, ‘fat’, ‘lumpy’, ‘curvy’ and ‘slender’, with a five-minute time limit on each picture. This enabled group members to experiment with the materials and discover their respective properties, as well as generating significant discussion. Group members discovered their connections with ‘fat’ as being ‘out of control’, ‘greedy’, ‘lazy’ and ‘ugly’ but also some positive associations of being ‘maternal’, ‘ample’ and ‘nonthreatening’. Similarly, ‘thin’ was experienced negatively as being ‘cold’, ‘competitive’, ‘ungenerous’ and ‘rigid’. ‘Lumpy’ was associated with ‘cellulite’ and ‘fat’, whilst ‘curvy’ posed a dilemma as it seemed connected with ‘femininity’ and ‘sexuality’ which for most group members were problematic areas.

Following this experience, group members chose whether to commit themselves to attending the programme.

The group programme

The group was structured to last for two hours with a flexible coffee break. A format evolved of using a mindfulness exercise at the start of the group. This was particularly useful to foster an observer position within the individual and a capacity to notice and tolerate feelings. Journals were used to record thoughts and feelings related to body image in between the group sessions and to highlight negative thoughts and their antecedent events. Guided imagery was used to gain a fuller awareness of their bodies in three dimensions and to indicate distressing thoughts and feelings. Information about the components of body image, typical negative thought processes and cultural standards regarding beauty and shape were discussed throughout the programme. Homework exercises included finding significant photos, looking after their bodies in particular ways (for instance, scented bubble bath) and recording their experiences. Group members also completed written questionnaires covering aspects of their body image history.

Inside out

Group members moved from literal depictions of their bodies to more evocative images associated with childhood memories. It became clear that negative parental ‘voices’ had been absorbed in the creation of highly critical beliefs about themselves. Phillipa had been described as ‘manipulative’ and ‘attention seeking’ when hurt or upset, whilst Trudy had been told she was ‘selfish and greedy’ when she wanted time away from her siblings.

A negative self-image served to protect the idealised parent. It was easier to conceive of oneself as ‘selfish’ than to acknowledge the deep pain of one’s mother being depressed and emotionally unavailable, or that father had a drink problem. Several group members felt that they were negatively perceived by their mothers for being ‘daddy’s girl’ and being close to their fathers. This dynamic was communicated in teenage years through competitive comments and overt criticism. Preserving these negative self-images protected them from further envious attack.

There were strong feelings that fulfilling one’s potential would mean being oppressive and dominating towards others. This seemed to be driven by their early experiences and a belief that there was only room for one important female in the house! There was no experience of being solid in oneself and using one’s power benignly.

It was apparent that, for some group members, their lack of early nurturance and acceptance had been translated onto their body. If they were good enough (thin enough), they would be loved. The above issues became apparent as group members depicted themselves within family portraits and drew significant memories from childhood. Early experiences of being put on diets as youngsters were tearfully discussed and the concomitant sense of humiliation and shame shared in the group. As anger swelled in the group it mobilised a desire for action and change. Group members helped each other rehearse interacting with family members differently and encouraged increased self-assertion.

For Julie, it also became apparent that her job as an aerobics instructor meant she was heavily invested in maintaining her belief system about her body weight and shape. As a child, Julie felt that teachers and adults had ignored her because she was obese. As a teenager her mother had ‘stolen’ her boyfriends, but now she held the admiring gaze of women watching her body whilst she instructed them. She was able to identify that she wanted to be ‘seen’ and to be the centre of attention in a positive way.

Another group member congratulated her for turning things around and commented that she thought she was special irrespective of her size. At times Julie found it difficult to take part in the group discussion and her attention was directed to finding split ends in her hair or checking her nails. At these moments, we tried to help Julie notice what feelings she had disengaged from and what this meant for her. She discovered that she switched her attention to her appearance when she felt different from the other group members and thus excluded. The members were able to help her reconnect with them and to include her different views as part of the whole group perspective.

As painful experiences were revealed in the group, members articulated the compulsion to return to their eating disorder to cut off from their feelings and reactivate the belief that controlling their bodies was the answer. The therapists endorsed that these feelings were usual at this stage of the process and we dedicated time to practising grounding techniques and developing a ‘safe place’ that group members could visualise and bring to mind. The women helped each other problem solve around current situations where their body image difficulties were likely to be activated.

One of the women in the aerobics class had commented on Julie’s stretch marks and she had felt worthless and nullified. This engendered a conversation about perfectionism and trying to accept being ordinary or ‘good enough’. Phillipa spoke of an impending school reunion and her desire to be more accepting of her own voice within her peer group. She wanted to go and be herself rather than compromise her integrity in a bid for acceptance and membership. Trudy was due to go on holiday with her original family but wanted not to accept the food choices that her mother still made on her behalf. She spoke of feeling attacked by the very person who should be protecting and supporting her and acknowledged her acute distress. She went on to do a ‘hurt and angry’ picture of sharp explosive shapes and commented that it felt much better to feel angry than hurt. She added that feeling anger meant that attempting adult interactions seemed possible for her.

Phillipa depicted herself amongst friends who appreciated her qualities and made her feel valued, an image too of the group experience. Julie wrote her name in bright colours filling the whole page. She said she had enjoyed doing it and it had made her feel good – she had put herself centre-stage in the image and had reasserted herself. Two other group members depicted the ‘safe place’ that they had created during the visualisation exercise.

Gains

It was noticeable over the ensuing weeks that, with the exception of Julie, the artwork depicted an increasing integration of good and bad elements represented on one page, rather than split, polarised extremes. Group members no longer required themes or direction for their artwork but were able to free-associate on paper. All group members had increased their understanding of themselves and their relationships and had become quick to identify significant themes and difficult triggers. They had met their internal worlds through a variety of media and could hold internal dialogues.

The significant gains in self-acceptance were exemplified by the work of one group member: Trudy created a series of images that developed from one of the therapist’s images of a seedpod held in the womb of the group. She did not have many words for these images but they seemed to have their own momentum and move steadily towards a sense of self. This series culminated in a green plasticine hand holding a golden shiny egg. Initially, she thought it might be about her need to be protected and held, but as she continued to talk she told us that it symbolised her recognition of her gifts and value, and that she did indeed have something to offer the world; she was, after all, a ‘golden girl’.

Ending

As the group met for its final session and members reviewed their artwork and the journey it represented, there were strong feelings of celebration for the supportive milieu they had created. There was also sadness about losing this motivating environment and anxiety about maintaining their achievements.

A week later we received a thank you card from one group member who told us that as she left the unit she had seen a family of swans. She had seen the parent swans with their group of signets earlier in her treatment and noted the little one’s brown feathers. As she left the final group, she observed that they all now had magnificent white feathers and were beautiful, fully grown swans. She said that she had felt so sorry to lose the support of the group but on seeing the swans she had realised that she had internalised the experience and that the group was a part of her.