ACT for Body Image Difficulties and Disordered Eating

I frequently struggle when trying to find referrals for therapists who work with individuals around issues of body image and disordered/dysregulated eating. The most common refrain I hear is “Oh, I don’t work with eating disorders.” Many of my colleagues even feel reluctant to work with individuals with subclinical levels of dysregulated eating or struggles with body image.

My sense is that there are probably many factors that contribute to clinicians’ reluctance to work with issues related to body image and weight. Many seem to feel like their training didn’t equip them to be effective in working with those difficulties. Some seem to buy into the stigma that clients who struggle with eating disorders and body image are “difficult”. But I also wonder if part of it could be because for many of us, it’s an issue that we have our own struggles with. Chances are, if you have a body, particularly if you are a woman in this culture and have a body, you have your own varying degree of dissatisfaction with it. And maybe because of that we feel like we aren’t the right ones to help someone else with those difficulties.  As clinicians, we know that we struggle with many of the same difficulties that our clients do; for example, many clinicians know first-hand the struggles of anxiety, depression, substance use, or trauma. But all these things can be hidden struggles. In contrast, our bodies are highly visible. Our bodies can be (and are) judged by ourselves and by our clients. Talking about issues related to food, body image, and weight often highlight that uncomfortable fact.

Many years ago, when I first started working with individuals around their body image difficulties, I felt an incredible hypocrisy. My body wasn’t (and still isn’t) shaped the way most people in American would say is the beauty ideal. Even so, I used to feel I needed to reflect back to my clients, even if only non-verbally, that I felt GREAT about my body, that I had conquered this whole body image thing and thus I could help them too by golly! Problem was that I didn’t and don’t always have universally positive thoughts and feelings about my body. No matter how hard I have tried, I too still have some of the same difficult thoughts and feelings about my body that my clients were coming to see me for; I too have a mind that was programed by this culture. So I was in a bit of a bind.

A different approach to body image struggles

But then I started studying  Acceptance and Commitment Therapy (ACT). From an ACT perspective, the problem isn’t that my clients or I had negative thoughts or feelings about our bodies. Rather than focusing on the importance of thinking or feeling more positively about our bodies, ACT suggests that what is most important is focusing on not letting those difficult thoughts or feelings stand in the way of doing what would be meaningful and important.  For some that will mean choosing to be physically intimate with your partner even if doing so will bring up self judgments about how you look naked. For others, it might mean exercising regularly so that you have the energy to be an active participant in your kids lives even though no matter how many times you go to that yoga class you might always have the same “YUCK!” thought that goes through your mind as you look into the mirrors at the front of the class.

ACT psychologist and assistant professor at University of Louisiana at Lafayette Emily Sandoz, Ph.D. is one of the country’s leading experts on in the area of body image and disordered eating. She is the author of several ACT books including Acceptance and Commitment Therapy for Eating Disorders, The Mindfulness and Acceptance Workbook for Bulimia, and the upcoming Mindfulness and Acceptance Workbook for Body Image. Dr. Sandoz’s recent interview in the Huffington Post offers a great synopsis on an ACT approach to dealing with body image concerns. In her interview, Dr. Sandoz highlights that in ACT we ask our clients the following questions:

“Would you be willing to have these terrible thoughts and feelings about your body if it meant you’re able to live the life you want to live? Would you be willing to feel distress about your body image if it meant you could be more present with your children? If it meant you could be more active in your community? If it meant you could pursue companionship? Would that be worth it to you?”

When I have a new client on my schedule and I see that eating dysregulation or body image are one of the presenting concerns, I still at times get a quick flash of anxiety. My own self judgments show up, as do fears about how I will be judged by that person I am about to meet. But then I practice what I encourage my clients to do; I thank my mind for that thought and then ask myself this question, “If I were free to choose, would I rather important trying to avoid having negative thoughts about my body or would I choose to important being fully present with this next person that is coming in to my office?”. Once I am centered on what is actually important to me,  I can get on to the valued work of connecting with peoples’ suffering, even when that suffering brings up discomfort for me.