The Complexity of Body Image: Relevance and Impact Across the Life Span
by Adrienne Ressler, LMSW, CEDS
“Hello, Gorgeous!” This greeting is not the one most individuals use to address the reflection looking back at them from the mirror. Rather, most use the mirror as a tool for taking stock of their worth—despite age, gender, socioeconomic status, religion, or race—conducting a critical search for flaws, fat, and proof of failure to live up to the standards they have set for themselves. The hunger for perfection is insatiable—a word derived from the Latin root satis, meaning enough and implying “capable of being satisfied fully.” For those with body image issues, the high is never high enough, the scale is never low enough, and the image in the mirror is never good enough. Body image dissatisfaction and distortion are key issues for most women and girls (and an ever-increasing number of boys and men), and not just those with an eating disorder. Unfortunately, few of us have peace of mind when it comes to our bodies and appearance—giving rise to body shame, body loathing, anxiety, low self-esteem, and a disconnection from our bodies. Ironically, as obsessed as clients with eating disorders are about their bodies, they are not really “living in,” connected to, or grounded in their bodies; rather, the body is seen as an object needing to be controlled. Clients will often refer to their bodies as “it” or “this body”—indicative of something outside of themselves. It is not uncommon to hear someone with an eating disorder describe her relationship with her body as that of one with a stranger or even an enemy (Kleinman & Hall, 2006).
Defining Body Image
Body image is often oversimplified and assumed to be merely a factor of “I love my body” or “I loathe my body.” It is a complex and multifaceted dynamic, integral to the life cycle, shifting and adapting as we age and engage in life experiences. The defining characteristics of a healthy body image make it clear just how far removed oureating disorder clients are from achieving satisfaction and a sense of wholeness in terms of their relationship with their body. A healthy body image is actually flexible; body representations reflect one’s inner sensations and intrapsychic events, and external events can change literally from moment to moment. As a counterbalance, the core body schema (the source of our drives and bodily needs) remains constant to provide a sense of stability. For individuals with body control issues, however, their images are rigid and unchanging. The mental image of their body is idealized, not realistic, and fails to match up with what the body actually looks like as perceived by others. Those with body image issues do not experience their body fully or with a sense of aliveness and energy; the body often appears “shut down” or “frozen.” Clients live in a world of images that fill their heads with fantasies, rarely capable of being present in the moment. Often, they do not have a sense of “living” in their body or being connected to it, yet the body holds much of our emotional history and experiences and serves as “the main vehicle for change, often acting as a map to hidden psychological issues” (Hull, 1997). While Cash (2008) cites more than 100 definitions currently in use in body image literature and research, the complex nature of body image for eating disorder clients is manifested in disturbances of perception, an inability to recognize signals and sensations from the body, delusional-like distortions of size and weight, and identity issues that involve differentiating “who I am” from “how I look” (Bruch, 1962). The simple working definition that follows is one that bridges communication between practitioners, families, and clients. Body image is “how I look to myself in my mind’s eye, how I believe others perceive me, and how I feel living in my body.” Bruch, a pioneer in eating disorder and body image research, stated, “Without corrective change in the body image, improvement is apt to be only a temporary remission” (1962).
In the Beginning
The development of body image actually begins prior to the infant’s birth. Expectant parents and family members often have hopes, dreams, and fantasies about what the looks and personality of the baby will be. The likelihood of positive attachment and bonding between infant and caretaker is increased when the pre-birth expectations are a close match with the reality of the little bundle who arrives on the “big day” (Fisher, Fisher & Stark, 1990). Empathic parenting, particularly in the early years, is critical because attuned responses to the infant’s signals and needs are vital to the attachment relationship that forms the baseline throughout life for capacity for connection. A reciprocal relationship with the caretaker, strengthened by soothing tone and touch, as well as eye contact (mutual gaze), promotes the development of trust, boundaries, and the initial ability to identify “who is me” from “who is not me.” Body awareness is heightened through stimulation of the body (chiefly through the skin) and the caregiver’s sensory-motor contacts with the child; well-renowned developmental psychologist Jean Piaget labeled this period the sensory motor phase. “At the beginning of life, being stroked, cuddled, and soothed by touch libidinizes the various parts of the child’s body, helps to build up a healthy body image and body ego, increases its cathexis with the narcissistic libido, and simultaneously promotes the development of object love by cementing the bond between child and mother,” wrote Anna Freud (Montagu, 1986). When elements central to empathic responses are provided for infants, their ability to “see the world feelingly” is enhanced, and a whole and intact body image without gaps or distortions results (Krueger, 2002).
Moving Through Stages
Developmental transitions create special risk factors—across age, stage, size, ability, ethnicity, race, place, class, gender, and sexual orientation and identity. At any age, developmental transitions create vulnerability because “normative external stressors require a major internal reorganization of the sense of self, including personality and cognitive and emotional structures. In essence, everything is in flux, both inside and out” (Maine, 2010). Stages of body image development are not finite, nor are they linear; they merge and overlap as the infant moves through the life cycle, sometimes moving backward (regressing and seeking the familiar) and sometimes forward (maturing).
Self and body image are developmental processes that undergo gradual maturational change around a cohesive core, similar to an intact psychological self. Early developmental disruptions in the process of establishing a stable, integrated, cohesive body image seem to result from any of several maladaptive interactive patterns that manifest as over-intrusiveness and overstimulation, empathic unavailability, or inconsistency or selectivity of response (Krueger, 2002). The more these maladaptive patterns are repeated and reinforced throughout the stages of the life span, the more likely it is that the individual will not develop the sense of wholeness and integration needed for establishing healthy connections to self and the world.
The core of the self is developmentally grounded in body experience. Helping clients reclaim the forsaken body is best accomplished when core body image treatment addresses the emotions and experiences embedded and imprinted in the body. When clinicians help clients become embodied, they are using a term, coined by Winnicott in 1965, synonymous with indwelling, “a seamless linkage of self, body functions, and the limiting membrane of the skin” (Krueger, 2002). Embodiment “weaves together the essence of the self as a whole being—emotions, thoughts, and actions in harmonious synchrony” (Kleinman & Ressler, 2015). It is the base upon which individuals can move forward in life, owning and living in their body.
First Steps and Beyond
Infants don’t stay infants for long. Driven by the rhythm, timing, and tempo of their own internal clock, they seem to magically turn into toddlers—a word derived from “to toddle,” which means to walk unsteadily—the gait of a child learning to walk. The toddler years, from about age 1 to 2½, are a time in which great cognitive, emotional, physical, and social developmental milestones occur. Perhaps only adolescence involves an upheaval similar in depth and breadth to that of the toddler period. Best described as a time of in between, the toddler is no longer a baby, but not yet a child. As Penelope Leach so beautifully points out, the toddler’s “developmental imperative of independence conflicts with the emotional imperative of love,” often resulting in moods that swing rapidly between cute antics or cooperation one moment and screaming, kicking, biting fits of rage the next (Leach, 1978). Unpredictable behavior and often unintelligible language must be decoded in order to fully understand what fears and frustrations underlie what the toddler displays outwardly. At this preoperational stage, another marker in body image development, increased separation and individuation, comes into play. Toddlers whose rearing balances the love/safety/comfort of the familiar with the adventurous exploration of new territory learn they can exist independently, thus promoting the likelihood of greater independence, self-image, and confidence in their body.
Young children have now learned the language of words to express themselves rather than relying almost solely on the language of the body. At this preoperational stage, whose upper range extends into about 5 or 6 years of age, not only do children see themselves as separate, but they also begin to recognize that others are separate themselves and exist as “real people.” This is an age of identification. Like a sponge, children observe and model the language, facial expressions, and behaviors of those surrounding them and become vulnerable to media influences. It is also a time when they seek out approval. Children growing up in an environment surrounded by “fat talk,” dieting behaviors, weight focus, and calorie counting are learning more than their ABC’s; they are learning a way of life that involves displeasure and dissatisfaction of the body. The potential for body-related problems can develop very early in life. Preschoolers, and those children on the cusp of entering Piaget’s stage identified as concrete operations, are particularly vulnerable to these attitudes, as they are busy learning how they fit into the larger picture. In their quest for acceptance, they cannot help but be influenced by a culture that places such a premium on thinness for girls and muscularity for boys. If they are concerned about their body at 3 or 4, the perception of never being good enough may escalate, not only to dieting behaviors at 6 or 7, but to a lifelong and incomplete distorted self-image imprinted in brain and body.
Negative attitudes about overweight emerge at an early age, and stigmatization of overweight children is already present in 3-year olds. Streigel-Moore and Franko (2002) write that it is estimated that as many as half of all girls ages 6 to 8 want to be thinner, and there appears to be a decrease in the age at which body image concerns emerge. Tweens (ages 8 to 11) are ripe for the media bombardment and self-awareness that accompany this vulnerable age range. Unfortunately, bullying, shunning, cliques, and emphasis on acceptance and popularity begin to create an environment that ranges from mean-spirited to downright hostile for those who do not “fit in” and takes on more force and velocity as this group moves into adolescence. As news journalist Eric Sevareid said years ago in 1964, “The biggest big business in America is not steel, automobiles, or television. It is the manufacture, refinement, and distribution of anxiety.”
Studies on girls show that robust, verbal bookworms lose their active voice at 10 and 11—shifting from a position of passion to one of complacency, and transferring their focus on real-life adventure to a focus on fitting in. With this comes dissociation from their bodies (Connor-Green, 1993). As early feminist Simone de Beauvoir said in the 1940s, “To lose confidence in one’s body is to lose confidence in oneself.” If young women are continuing to be shamed, girls will stop following their dreams and achieving to the best of their ability, because they are worried that they won’t be accepted for their size. Yet change in size is specifically what puberty is all about. Usually after a girl’s 8th birthday or a boy turns 9 or 10, puberty begins when the hypothalamus starts to release gonadotropin-releasing hormone, which travels to the pituitary gland and releases two more puberty hormones: luteinizing hormone and follicle-stimulating hormone. Simultaneously, the adrenal glands are activated. Based upon on the sex of the individual, the results are different for height and weight changes, modifications in shape (broader shoulders, and increased size of penis and testicles for males; fat storage through the abdomen and broader hips for girls). Preadolescent females acquire what, in common language, is often called “baby fat,” which may give them a more rounded belly—a development that may cause considerable anxiety.
The word that best describes this phase is awkward. In addition to physical and sexual changes that seem to have a life of their own, preteens are confronted by social pressures and expectations that they may be ill-prepared to take on. The seeds of body shame often are planted in the rocky garden of this period and bloom fully at adolescence.
Piaget (1947) defined adolescence as “a decisive turning point … at which the individual rejects, or at least revises, his estimate of everything that has been inculcated in him and acquires a personal point of view and a personal place in life.” This can be a daunting task—particularly coming of age feeling ill-equipped to handle the process. While the perfect storm of social, emotional, and physiological changes that descends on the adolescent can be mitigated somewhat by the fortune of being born with a calm, even-tempered, stable personality, the sheer number and intensity of issues that emerge can be overwhelming. In the past, body dissatisfaction was seen as giving rise to anxiety and insecurity, but researchers in personality are now looking at how an anxious temperament can change one’s outlook on the world and contribute to a poor image of one’s own body. “One individual’s lens will allow for a very positive view of the world and the body, yet another’s lens will lead to distress” (Dionne & Davis, 2012). The farther one views oneself from the cultural beauty ideal, the greater one’s body dissatisfaction. Worry, anxiousness, self-consciousness, and oversensitivity to criticism are traits that at high levels correspond with elevated levels of body dissatisfaction. Divergent expectations from family, religion, race, socioeconomic status, and gender may cause conflict, adding to stress, while the impact of the social realm involves exposure to multiple forms of social stimuli, such as social and print media, pop culture, school culture, and society, all of which add to the dilemma of how one can fit in. Adolescents are faced with decisions that pique their vulnerability—striking out for new horizons with unfamiliar territory to be navigated. College culture has its own version of body image pressure in view of the concerns about lack of safety on campus for both females and males. Fear of rejection or humiliation at being singled out adds to the likelihood of conforming to body standards in order to avoid being shamed or in an attempt to distract oneself from emotions difficult to tolerate. For females, a large body of literature documents the pervasiveness of body image concerns fueled by weight gain during the first year of college. Indeed, the pervasiveness of body image concerns in adolescent girls has been hypothesized to contribute to the emergence of the gender disparity in depression during adolescence. The body itself may become a “shame container” (Shure & Weinstock, 2009) or endure neglect, its needs usurped by external expectations rather than those needs being met through a recognition of one’s internal sensations, emotions, and communications. Sadly, allegiance to the culture and its expectations too often trumps personal satisfaction.
Adulthood, Midlife, and Beyond
In some cultures, the older individuals are, the more they are revered. That is not true in the United States or other industrial countries. The pursuit of thinness and youth has become normative for females. Increasingly, drastic means of body shaping, sculpting, augmentation, and reduction in cohort with the skill of cosmetic surgeons has created a socioeconomic chasm between the “haves” and the “have-nots.” Hillel Schwartz, in Never Satisfied: A Cultural History of Diets, Fantasies, and Fat (1986), provides a historic look at the business and politics of body size and weight, which underscores the point that in every decade the driving force behind attempts to change the body is a belief in transformation—“I will no longer be me; I will be a better, happier, lovable, popular, employable, sought-after me.” This myth is pervasive throughout the life span and only increases with age as individuals move farther and farther from the cultural beauty standard. A study by Tiggemann and Lynch (2001) suggests that women (ages 20 to 84) continue to struggle with issues related to changing shape and size throughout the life cycle. Of note is information that although body dissatisfaction was found to remain relatively stable across the life span, the meaning of the weight did not remain constant across age groups; less body monitoring, anxiety over appearance, and dieting to lose weight, along with larger ideal body shapes, were reported by older women. This may suggest that the psychological impact of body dissatisfaction may decrease as women age.
Adult life for both women and men is filled with transitions and stressors that have an impact, not only on their lives but also on their body image. Maine (2010) cites the complications of a changing, aging body, plus multiple role changes from school to career to marriage, mothering, divorce, empty nesting, and caring for older parents, as well as health and mortality issues, as just some of the stressors encountered by adult women. While males may have some overlap with these concerns, with age may come the pressures to be at the top of their game—both professionally and socially. In a competitive male world, there are always younger contenders with abundant energy, knowledge of the latest technological gadgets, and a lifetime contract with the local gym. While men’s concerns center more on muscularity than thinness, issues of sexual performance and hair loss are often the focus of insecurity and anxiety. Many women face issues of motherhood vs. career, a ticking biological clock, and possibly feeling betrayed having bought into the myth that “women can have it all.” While there may now be more professional opportunities that allow women to be more visible, conversely, women in the limelight are often targets for body judgment and commentary.
As women age, the stage of life that involves menopause cannot be overlooked. There is no Viagra counterpart on the market for women to ease the passing of youth, but for many women able to understand this cycle, honoring this passage can be healing and affirming. More and more, there are female role models for women, as they age, to admire and emulate—many older than 50, 60, 70, and 80 who possess confidence, satisfaction, and wisdom. “Old is not a thing. We’re the same people, going through a different stage,” said Gloria Steinem in a 1995 Mother Jones interview (Gorney, 1995). She continued – we are turned into female impersonators by age 10 and only when you reach 60 can you be who you really are (paraphrased). Her words echo those of Mary Ann Evans, who, writing under the male pen name George Eliot in the 19th century, stated this anthem for women of her day: “It is never too late to be what you might have been.”
Body-Focused Methods to Reclaim the Forsaken Body
As the field of eating disorders has matured, embracing the use of body-focused interventions to bring the body back into body image has become an essential element of careful, comprehensive, and effective treatment. Experiential methods, which involve healing beyond words, are a means to help clients reclaim their connection to their body and access the imprint and impact of stored memory and experiences, no matter at what stage in life. Clinicians and clients alike benefit from working within a holistic framework that reflects the powerful synchrony between body and mind. When clinicians invite opportunities for creativity and spontaneity to emerge, authenticity, growth, and connection are maximized.
The following are suggestions to help integrate a body-focused perspective, along with some examples of activities to use to bring the body back into body image treatment.
- Overall Impression
Tune in to the “essence” of the client’s body. This will help you notice holding patterns and many of the physiological signals that can be decoded and addressed as “body language.”
Body image impressions are useful along a continuum for each of the following parameters:
Structure Rigid to Loose
Energy Shut Down to Chaotic
Containment Holding In to Spilling Over
Boundaries Impermeable to Wide Open
Musculature Underdeveloped to Overdeveloped
Movement Clumsy/Awkward to Posed/Tight
Breathing Shallow to Panting
Balance Stuck to Off Center/Extreme
2. Act Out Body Image Words
Observe patterns in the client’s language that reflect “body image” words, such as, “I feel stuck,” “I’m so huge,” or I’m scared to “stand on my own two feet.” Point out the “physical” nature of the words, and explore how the body is playing out these concerns or conflicts. Often, the client may consent to act out or position the body in such a way as to re-create these feelings. For example, one patient placed herself in a corner while exploring her feelings of being trapped and subsequently became aware of body sensations she had formerly suppressed. She then practiced “breaking free” until she built that skill into her body on both a physical and metaphorical level.
3. Body “Language”
Notice “emotion” words in the client’s language and ask where those feelings are stored in the body. Then explore the significance of that body part. As one patient stated, “My sadness is heavy in my stomach.” Note both positive as well as negative feelings.
Encourage participation in activities such as tai chi, karate, yoga, or self-defense that promote centering and grounding, to keep a positive focus on the body. These activities, while scary for many clients initially, may significantly enhance mind-body congruity. Simple grounding techniques can be taught within the context of your session through physical reality checks by asking, “How are you feeling in your body now?” or by having your clients stand and plant their feet on the floor and send energy through the head down through the body into the ground.
Clients often compartmentalize their body parts. Remind them that they are a whole person and that each body part is connected to the whole. Positive rituals for self-soothing heighten a sense of connection and reduce feelings of isolation in and from the body.
6. Encourage Touch
Reconnecting to the body through self-touch encourages self-nurturing and a sense of belonging in the body. Soothing touch is both calming and energizing. It provides a reality check for body boundaries. For those clients who are able to tolerate massage, their sense of the body is greatly restored and systems reduced. (See “Anorexia Nervosa Symptoms Are Reduced by Massage Therapy,” Eating Disorders: The Journal of Treatment & Prevention, Winter 2001.)
Observe your client’s breathing. Shallow breathing or holding the breath will cut off feeling in the body. Teach relaxation breathing. Remind your client to breathe fully to keep the body sensations open and alive. Yoga breathing is very helpful.
8. Self-Compassion and Reframing
Remember that body image appears to be intimately linked with personal identity. Help clients replace the body image identity that captures the essence of the negative framework (“I am disgusting”) with the word that captures the essence of the positive or healthy identity (“I am radiant”). Studies show that self-compassion plays a major role in decreasing negative body attitudes—it is a way to soothe oneself.
Reclaiming the forsaken body means a return to real feelings, which can be experienced and expressed. The client whose existence is caught up in a created image is blinded to life and its feelings. “It is the body that melts with love, freezes with fear, trembles in anger, and reaches for warmth and contact,” writes Alexander Lowen, MD, in his book, The Betrayal of the Body. Reclaiming the body restores a whole and complete body image.
Note: Precautions must be followed in working with the body. As a practitioner, closely examine your own size and weight preferences and be aware of issues that might affect countertransference and mutuality. Have respect for clients’ boundaries and gauge their readiness for an incorporation of some body-focused methods.
For more on this topic, readers might reference chapters on holistic and experiential methods in two textbooks: Effective Clinical Practice in the Treatment of Eating Disorders: The Heart of the Matter and Treatment of Eating Disorders: Bridging the Research-Practice Gap. In addition, the Encyclopedia of Body Image and Human Appearance holds a wealth of information and research.
About the author –
Adrienne Ressler, LMSW, CEDS is Vice President, Professional Development, for The Renfrew Center Foundation and has served as senior staff for over 25 years.
Adrienne attended the University of Michigan and held a faculty appointment in the School of Education.
A body image specialist, she is a member of the Academy of Eating Disorders and serves as co-chairperson of the Academy’s Somatic Therapies Special Interest Group. She is a Fellow and past president of the Board of Directors of the International Association of Eating Disorder Professionals (iaedp).
Adrienne’s trainings and writing reflect her background in body-focused methods to treat eating disorders and body image. She is published in the International Journal of Fertility and Women’s Medicine, Social Work Today and Pulse, the journal of the International Spa Association.
Author of chapters on the use of experiential and creative therapies for eating disorders in two textbooks, Effective Clinical Practice in the Treatment of Eating Disorders: The Heart of the Matter and Treatment of Eating of Eating Disorders: Bridging the Research-Practice Gap, her work has also been included in the first Encyclopedia of Body Image and Human Appearance. A frequent contributor to the popular media, she has appeared on the Today Show and Good Morning America Sunday.
Adrienne lives in Fort Lauderdale, FL, and is an avid baseball and hockey fan.
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