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Eating Disorders Eating disorders can plague both males and females, and they generally have different unattainable physical


Eating Disorders Eating disorders can plague both males and females, and they generally have different unattainable physical

 

Assignment: Eating Disorders

Eating disorders can plague both males and females, and they generally have different unattainable physical appearance-related goals. Males may feel the need to develop large muscles and are more vulnerable to taking drugs or embarking on exercise regimens that move them in that direction. For males who are obese or disinterested in athletics, there may be considerable social pressure and harassment to increase their muscle mass or overall strength. Females tend to gain weight and body fat during puberty. This tendency is in direct opposition to the “skinny” images they are exposed to through the media. As a consequence, girls are more likely to diet and exercise in ways that emphasize thinness and weight loss instead of fitness. These actions can result in eating disorders. Anorexia nervosa, the act of starving oneself, and bulimia nervosa, the act of binging and purging, are chronic conditions among many children and adolescents.

For this Assignment, consider the differences between normal variations in body image and what constitutes an eating disorder. In addition, consider what types of interventions are most effective with children and adolescents with eating disorders.

The Assignment (2–3 pages):

  • Explain two differences between normal variations of body image and a diagnosable eating disorder.
  • Explain three key elements that you would include in an intervention for the prevention of eating disorders.
  • Explain which of the three key elements would be developmentally appropriate for children and developmentally appropriate for adolescents, and explain why.
  • Explain which of the three key elements might apply best to males and which of the three key elements might apply best to females, and explain why. Be specific.
  • Justify your response using the week’s resources and the current literature.

Body Image 1 (2004) 15–28

Body image in children and adolescents: where do we go from here?

Linda Smolak∗

Department of Psychology, Kenyon College, Gambier, OH 43022, USA

Received 15 June 2003; received in revised form 17 July 2003; accepted 17 July 2003

Abstract

During the past two decades, there has been an explosion of research concerning body image in children and adolescence. This research has been fueled both by concern about the effects of poor body image in children and adolescents themselves and by the assumption that body dissatisfaction during childhood and adolescence creates risk for the development of body image and eating disturbances as well as depression in adulthood. The extant research, however, has remained largely descriptive and is marked by methodological problems. The purpose of the present paper is to identify substantial gaps in the literature concerning body image in children and adolescents. The focus is on four major issues: (1) measurement, (2) epidemiological data, (3) developmental trends, and (4) the meaning of gender. Addressing these and related questions will aid in the development of treatment and prevention programs. © 2003 Elsevier B.V. All rights reserved.

Keywords:Childhood; Measurement; Development; Gender

Introduction

It is invariably instructive to interview children about their appearance. There are the children, most typically average size girls, who lower their eyes, heads, and voices as they answer the questions on the Body Esteem Scale (BES;Mendelson & White, 1993) and tell us that no, they do not like the way they look in pictures, yes, they wish they were thinner, and no, their classmates do not want to look like them—why would anyone want to look like them? There are the young children who are already modifying what they eat or doing aerobics with their moms in order to

∗ Tel.: +1-740-427-5374; fax:+1-740-427-5237. E-mail address:[email protected] (L. Smolak).

lose weight. They surprise us with their knowledge of weight loss and body sculpting techniques, specify- ing commercial diet programs, such as Jenny Craig, by name. Even more stunning was the first grader who told us you would need to throw up after eat- ing or the elementary schoolers who thought plastic surgery would be necessary to achieve the body ideal portrayed by Christina Aquilera or Britney Spears (Murnen, Smolak, Mills, & Good, in press).

These experiences point to one of the reasons re- searchers, educators, and parents are concerned about body image in children. It is clear that some children are already worried about their ability to look “good enough” to be accepted by others. They are saddened and embarrassed by their looks. They are already try- ing food restriction and exercise techniques to change

1740-1445/$ – see front matter © 2003 Elsevier B.V. All rights reserved. doi:10.1016/S1740-1445(03)00008-1

16 L. Smolak / Body Image 1 (2004) 15–28

their bodies. Some of these attempts may be health endangering. Thus, there seem to be children whose lives are already being negatively affected by poor body image.

These anecdotes also raise the possibility that the foundation of body dissatisfaction is laid in childhood. There is prospective, longitudinal evidence that ado- lescent body dissatisfaction and especially concerns about being or becoming fat is related to the develop- ment of eating problems, eating disorders, and depres- sion (e.g.,Leon, Fulkerson, Perry, & Early-Zald, 1995; McKnight Investigators, 2003; Stice, 2002; Stice & Bearman, 2001; Stice, Hayward, Cameron, Killen, & Taylor, 2000; Wichstrom, 1999). Finding the roots of this risk factor will be crucial in both the prevention and treatment of eating disorders and depression.

But experiences and anecdotes are not data. There is now a sizeable body of studies of body image in children and adolescents (for reviews, seeRicciardelli & McCabe, 2001a; Smolak & Levine, 2001), but there are even more unanswered questions. The purpose of this paper is to raise four broad questions, each with several accompanying specific issues that need to be addressed empirically. These issues focus on (1) mea- surement, (2) epidemiological data, (3) developmental trends, and (4) the meaning of gender. Research on these, and related, questions will expand our knowl- edge base about body image in children which will, in turn, provide an empirical foundation for preven- tion and treatment programs for body image and eat- ing problems.

How should we define and measure body image in children?

Researchers have long argued that body image is multidimensional with at least perceptual, affec- tive, cognitive, evaluative, and investment/behavioral components (e.g.,Muth & Cash, 1997; Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999). These dis- tinctions have been supported empirically in adoles- cents and adults (e.g.,Muth & Cash, 1997; Thompson, Altabe, Johnson, & Stormer, 1994). These distinctions have rarely been addressed in research with children, though they occasionally surface in research with ado- lescents (e.g.,Ricciardelli & McCabe, 2003). Indeed, several of the measures of body esteem commonly

used with children, such as the BES, cover a broadly defined construct and do not allow the researcher to specify the body esteem problem.

In addition, current research does not generally have a way to identify problematic levels of body dissatisfaction. AsCash (2002a)has argued with respect to defining “negative body image,” dissatis- faction alone is an insufficient criterion; the emotional and behavioral consequences of such dissatisfaction must the considered. If body dissatisfaction is in fact a “normative discontent” (Rodin, Silberstein, & Striegel-Moore, 1985) among girls and women, it is important to distinguish the girl who is engaging in socially sanctioned “fat talk” for the sake of seeming friendly from the child who is on a path to eating disorders or depression. While a few studies have identified “cut-offs” for weight concerns among ado- lescents for identifying girls at risk for developing eat- ing problems (e.g.,Killen et al., 1996), such research is not available for children. Nor have similar cut-offs been established for ethnic minority girls or for boys.

Evaluative body image

Body image evaluation, which refers to how sat- isfied one is with one’s body (Muth & Cash, 1997), is probably the most common aspect of body image that is measured in children. This is also sometimes referred to as attitudinal body image (Gardner, 2002). Both figure drawings and questionnaires have been used to assess body dissatisfaction in children and ado- lescents.

Being able to evaluate one’s body requires that the child can assess her/his own body, has an ideal to which to compare her/his body, and is capable of mak- ing such a comparison. It is possible that one must be more than aware of the ideal; perhaps the ideal needs to be internalized (Thompson & Stice, 2001) before meaningful body dissatisfaction will develop. Clearly, these components are in place by adolescence. But when do they first appear?

In terms awareness of the culturally defined ideal body, there are data indicating that 5 year olds have absorbed the cultural bias against fat peo- ple (Cramer & Steinwert, 1998; Musher-Eizenman, Holub, Edwards-Leeper, Persson, & Goldstein, 2003). Three year olds may also be aware of the anti-fat

L. Smolak / Body Image 1 (2004) 15–28 17

prejudice but they are less committed to it. They are less likely to ascribe negative characteristics to fat children than 5 year olds are (Musher-Eizenman et al., 2003). However, the 5 year olds have a wider range of what constitutes an acceptable body type than do adults (Musher-Eizenman et al., 2003).

Unfortunately, these studies are marked by method- ological problems. The samples tend to be small as well as white and middle-class, the designs are cross-sectional, and there are questions about the measures. For example, it is not clear that preschool and even early elementary school children can use checklists of fairly abstract personality characteris- tics (Musher-Eizenman et al., 2003). Indeed, they do not use these types of terms to describe other people (Ewell, Smith, Karmel, & Hart, 1996). Researchers have not looked at whether measures such as the Sociocultural Attitudes towards Appearance Ques- tionnaire (SATAQ;Heinberg, Thompson, & Stormer, 1995) that measure awareness and internalization of the thin-ideal are valid with preschool and early ele- mentary school children, although revised forms do appear to have validity with adolescents (Smolak, Levine, & Thompson, 2001). Musher-Eizenman et al. (2003) developed a story-based measure of fat prej- udice. However, they do not provide psychometric data, such as test–retest or internal consistency for the measure. There are, then, questions as to how to measure body ideal and fat prejudice in young children.

There are also questions as to how children report their “current” body types. Ideally, construct validity of a measure would be assessed by correlating the child’s actual BMI with the selected “current” figure (in figural measures) or the chosen body shape cat- egory (in questionnaires). Unfortunately, BMI stan- dards vary by age and gender. Therefore, it is not clear that BMI in preschoolers carries the same meaning that it does in adults. Researchers have used BMI, BMI per- centile (based, for example, on the Centers for Disease Control data), and ponderal index (height/ 3

√ weight)

to assess levels of weight for height among children. Without a valid criterion, it will be difficult to estab- lish the construct validity of the child’s own body rat- ings. Research must examine the relationships of BMI, BMI percentiles, and ponderal index in young chil- dren to future weight, body dissatisfaction, and eating problems.

Figure drawings

Despite the problems with establishing the validity of the current and ideal body shape components, there are several versions of figure drawings that have been used in research with children and adolescents. For many of these, few or no psychometric data are avail- able (seeGardner, 2001, 2002, for reviews). Proba- bly the most commonly used of child figure drawings measure was developed byCollins (1991). In her arti- cle, Collins (1991)reports an overall 3-day test–retest coefficient for current self of first to third graders of 0.71. She does not report this correlation by grade though she notes that figure selections “were stable in many instances. . . but dropped sporadically in others” (Collins, 1991, p. 203) when the analyses were per- formed by grade and gender. The test–retest correla- tions for other figure selections, including ideal self, ideal other child, and ideal adult, did not reach the acceptable level of 0.70 despite an interval of only 3 days. Furthermore, criterion validity correlations, though statistically significant, were not impressive. The correlation between pictorial self-selection and weight was 0.36 while the correlation between BMI and self rating was 0.37.

There are even fewer data available for preschool age children. Not surprisingly, the news is worse. Using an adaptation ofCollins’s (1991) figures, Musher-Eizenman et al. (2003)found no correlation between preschool children’s height or weight and their “current” body size rating. They did find a sub- stantial correlation of 0.84 between the children’s mothers’ ratings of maternal current body size and ma- ternal BMI. Thus, while heavier adult women actually select drawings depicting heavier people, children’s selections are unrelated to their actual body size.

Quite simply, we do not have the validity data to reliably use figure drawings with young children (approximately≤8 years old). In fact, the data have not been collected to clearly indicate at what age the current and ideal ratings, and hence the body dissat- isfaction measures they constitute, become reliable, although questionnaire data indicate that adolescents’ ratings should be reliable.

Questionnaires

Many researchers have simply asked adolescents a single question such as “How satisfied are you with

18 L. Smolak / Body Image 1 (2004) 15–28

your appearance?” The only construct validity we have for such questions is that they often show the expected correlations with weight control strategies or eating problems. Typically, test–retest is not reported.

One of the best available scales for assessing body dissatisfaction among older children and adolescents is the Eating Disorders Inventory Body Dissatisfaction scale (EDI-BD;Garner, Olmstead, & Polivy, 1983). Adequate internal consistency has been reported with girls as young as 8 and for both boys and girls aged 11–18 years (Shore & Porter, 1990; Wood, Becker, & Thompson, 1996). It also does seem to focus on the evaluation component of body image. However, be- cause this scale was developed to focus specifically on body areas of greatest concern to females with eat- ing disorders, its content narrowly emphasizes feelings about one’s hips, thighs, buttocks, and stomach.

Several other measures, especially the BES (Mendelson & White, 1993) and weight concerns (Killen, 1996; Shisslak et al., 1999) have also shown good internal consistency and reasonable test–retest reliability. In the case of weight concerns, these forms of validity have been demonstrated in children as young as fourth grade (Shisslak et al., 1999). Further- more, weight concerns has been shown to predict the development of eating disorders, at least among ado- lescents (Killen et al., 1996; McKnight Investigators, 2003). Unfortunately, weight concerns mixes evalua- tive and investment aspects of body image and so can be difficult to interpret. Furthermore, one attempt to use it with 5–9 year olds indicated poor internal con- sistency (α < 0.70; Davison, Markey, & Birch, 2003).

Affective body image

There are several self-esteem scales that tap feelings about body or appearance in children and adolescents. These are only occasionally used by body image re- searchers. However, some of them do demonstrate at least internal consistency and test–retest reliabil- ity and so should be considered more thoroughly by body image researchers. They might even serve as criterion variables for researchers trying to develop “purer” measures of body image focusing on mus- cles or weight. These scales include the Self-Image Questionnaire for Young Adolescents (Petersen, Schulenberg, Abramowitz, & Offer, 1984), the Offer Self Image Questionnaire (Offer, Ostruv, & Howard,

1984), and the Harter Scales (Harter, 1985). Harter’s Scales are applicable to both children and adolescents and so may be particularly useful in longitudinal research.

Body image investment

Body image investment involves both cogni- tive and behavioral indicators of the importance of one’s appearance to one’s sense of self. Several re- searchers have offered lists of weight control tech- niques or muscle-building techniques to boys and girls (e.g.,Levine, Smolak, & Hayden, 1994; Shisslak et al., 1999; Smolak et al., 2001). Perhaps one of the better-developed measures isRicciardelli and McCabe’s (2002)Body Change Inventory. This scale consists of three subscales: strategies to decrease body size, strategies to increase body size, and strategies to increase muscle size. As such, it is applicable to both boys’ and girls’ body concerns since boys may be as interested in gaining as in losing size (Smolak & Levine, 2001). There is also some evidence that African American girls may be interested in gaining size (Thompson, Corwin, & Sargent, 1997), so this scale may be of interest to researchers investigating ethnic differences in body image.Ricciardelli and McCabe (2002)report extensive exploratory and con- firmatory factor analyses in the development of these scales as well as concurrent and discriminant validity. The scale was developed for use with adolescents, with 11 year olds being the youngest children in their samples.

Body image schema

Several authors have suggested that a body image schema guides the interpretation of sociocultural in- fluences, such as media images (Cash, 2002b; Markus, Hamill, & Sentis, 1987; Smolak & Levine, 1994, 1996, 2001; Smolak, Levine, & Schermer, 1998; Vitousek & Hollon, 1990). The schema serves as a mediator be- tween the sociocultural influences and poor body im- age. The schema is thus crucial in understanding why some people are so negatively affected by sociocul- tural influences while others are not.

Smolak and Levine (1994, 2001)have further ar- gued that such a schema, which they term a “thinness schema,” develops during childhood and is in place,

L. Smolak / Body Image 1 (2004) 15–28 19

at least in an immature form, by early adolescence. They suggest, then, that young children will be rel- atively less resistant to the messages in universal prevention programs. These children will not yet have integrated beliefs about appearance—including cul- tural ideals, the importance of meeting such ideals, and the means to attain such an appearance—with each other into a cognitive schema. Furthermore, the children will not have fully integrated such ideas into their self-systems. It is for this reason that Smolak and Levine have argued strongly for universal prevention programs aimed at elementary school age children.

The ability to measure the development of body im- age schemas has theoretical and applied importance. Cash, Melnyk, and Hrabosky (in press)have devel- oped a measure to assess body image schemas among adults. The Appearance Schemas Inventory-Revised (ASI) has two factors. One factor measures the self-evaluative salience of one’s appearance (e.g., “What I look like is an important part of who I am.” “When I meet people for the first time, I wonder what they think about how I look.”), while the other factor assesses the simpler motivational salience of appearance (e.g., “Before going out, I make sure that I look as good as I possibly can”) (Cash et al., in press). Cash and his colleagues have presented substantial psychometric information concerning this scale using a college-age sample.

No comparable measure is available for children or even young adolescents. Given the argument that the thinness schema is gradually constructed during childhood (Smolak & Levine, 1994, 1996, 2001), it will be crucial to develop and validate a measure that might tap into the developmental process.

Summary

There are tools for measuring body image in chil- dren. As one might expect, they are not as extensively developed as those available for adults and even for adolescents. What is surprising is how very lim- ited our assessment arsenal is. We are especially ill equipped to measure body image in children who are under 10 (third grade or younger in the United States). It is absolutely imperative that new measures be developed and that both new and existing measures be more rigorously subjected to psychometric evalua- tion. Such work is time consuming and can even seem

tedious at times. It is often difficult to get schools to agree to participate in research whose primary aim is assessment development. Yet, the questions raised in the remainder of this chapter—and indeed all ques- tions concerning body image in children—cannot be answered without such research.

How are body image problems distributed?

In reading the popular press, it is not unusual to see figures suggesting that as many as 60% of ele- mentary school girls are dissatisfied with their bodies. Such numbers are usually based on a single study. In reviewing several studies,Smolak et al. (1998)con- cluded that it was fairly common to find that about 40% of late elementary school (typically fourth and fifth grade) girls reported body dissatisfaction.

Even this is a misleading number, however. First, the studies have fairly small samples, at least in terms of epidemiology. Second, the samples are overwhelm- ingly white. It is not clear that girls from ethnic mi- nority groups, particularly black girls, share the same body image concerns as white girls do. Third, there are several different measures used in the studies, some of which focused on body in general, others on weight and shape per se.

These concerns do not even address several im- portant limitations. First, boys are not well repre- sented. While research is now appearing that looks at boys’ body image (e.g.,Corson & Andersen, 2002; Ricciardelli & McCabe, 2003; Smolak et al., 2001), there are no epidemiological data available. Second, ethnic groups’ differences are poorly understood. Third, we have few data on children under 10.

Such limitations make it difficult to establish when body dissatisfaction becomes a problem. For exam- ple, when are ideal-current figure rating differences large enough to indicate a body image problem may exist? Without large-scale standardization studies and epidemiological data, it is difficult to know what is an unusual or pathological level of body dissatisfaction.

What are the developmental trends in body image development?

Similarly, we know little about the development of body image, particularly during the preschool and

20 L. Smolak / Body Image 1 (2004) 15–28

early elementary school years.Davison et al. (2003) reported an improvement in body esteem during the early elementary school years (ages 5–9 years). During middle school, both boys and girls seem to experience a decrease in body esteem although boys’ decrease may be less dramatic and may show a faster recovery than girls’ decrease does (e.g.Abramowitz, Peterson, & Schulenberg, 1984; Rosenblum & Lewis, 1999; Wichstrom, 1999).

It is not yet clear at what point body image becomes reasonably stable.Davison et al. (2003)reported significant, but small to moderate (r = 0.23–0.37) correlations between body esteem at ages 5, 7, and 9, Smolak and Levine (2001)reported no significant re- lationships between body esteem measured in grades 1–3 and again 2 years later.Smolak and Levine (2001) also reported that body esteem measured in fourth or fifth grade was related to body esteem mea- sured 2 years later.Cattarin and Thompson (1994) similarly found that body dissatisfaction was quite stable in a group of 10–15-year-old girls followed over a 3-year period. Both theDavison et al. (2003) and theSmolak and Levine (2001)studies had rela- tively small samples of white girls, leaving us a long way from establishing when stability of body image occurs.

Developmental trends must be mapped for the var- ious components of body image. It is not necessarily the case that evaluation, affect, and investment develop in tandem. Indeed, it seems likely that evaluation pre- dates investment. Some studies have found, for exam- ple, substantially fewer elementary school aged girls engaging in dieting than reporting body dissatisfaction (e.g.Smolak et al., 1998). This finding is underscored by the considerably lower correlations between body dissatisfaction and measures of dieting in elementary school girls when compared to those of adults (Smolak & Levine, 2001). The value of either the individual components or their interrelationships to predict de- pression or eating problems or even later body image problems is also an important developmental issue.

Risk factors and protective factors for the devel- opment of body image problems may also change. Several risk factors (seeStice, 2001, 2002, for re- views) that appear to foster body image problems in adolescence and adulthood also may be operative in childhood. For example, media influences and parental comments appear to affect body image by late ele-

mentary school (e.g.,Field et al., 1999; Smolak et al., 1998; Taylor et al., 1998). Sexual harassment is re- lated to poorer body esteem, at least among girls, in elementary school (Murnen & Smolak, 2000). Many of these studies are cross-sectional and most involve only white girls. There is much work to be done on risk factors for body image problems, particularly dur- ing the preschool and early elementary school years.

BMI may be a particularly interesting example of a risk factor whose meaning may change across childhood. BMI is correlated with body dissatisfac- tion in both adolescent and adult men and women. Body dissatisfaction may show a curvilinear relation- ship for men and a linear relationship for women and concerns about being fat may be more clearly tied to being overweight for men than for women (e.g., Dornbusch et al., 1984; McCreary, 2002; Muth & Cash, 1997). In the preschool years, children’s body size is not related to their appraisal of their current body type (Musher-Eizenman et al., 2003). Davison et al. (2003)reported small but significant correla- tions between BMI and body dissatisfaction in 5–9 year olds. The size of the correlations increased with age (r = 0.13–0.27). Davison, Markey, and Birch (2000) reported a correlation of 0.17 between BMI and body dissatisfaction for 5-year-old girls while the comparable correlation for the girls’ mothers was 0.77 and for their fathers was 0.61. Weight concerns were not associated with weight status among the 5 year olds.

The lesser strength of the relationships between BMI and body esteem in younger children is con- sistent with the argument that fat prejudice increases with age (Cramer & Steinwert, 1998; Wardle, Volz, & Golding, 1995). It is also consistent with Levine and Smolak’s argument (Levine et al., 1994; Smolak & Levine, 2001) that the “thinness schema,” a cognitive structure integrating thin-ideal, body dissatisfaction, and weight control techniques, may be less consoli- dated in younger children than in adolescents. If this is so, then elementary school may be a particularly appropriate time for universal programs aimed at pre- venting body image and eating problems. Thus, the BMI-body dissatisfaction relationship demonstrates the importance of charting changing patterns in the development of body image.

Even among adults, there is little research concern- ing factors that might protect against the development

L. Smolak / Body Image 1 (2004) 15–28 21

of body image and eating problems (Crago, Shisslak, & Ruble, 2001). Murnen et al. (in press)reported that elementary school girls who actively reject the sexu- alized thin-ideal media image of women have higher body esteem.Smolak, Murnen, and Ruble (2000) found that high school girls participating in non-elite sports had better body esteem whileGeller, Zaitsoff, and Srikameswaran (2002)reported that basing com- petence on academic and other activities (including sports), rather than on appearance, was associated with more positive body esteem in high school girls. In 5- and 7-year-old girls, participation in aesthetic sports (e.g., dance or gymnastics) has been correlated with higher weight concerns, a relationship that echoes that found with adults (Davison, Earnest, & Birch, 2002). However, participation in non-aesthetic sports (e.g., basketball or soccer) did not emerge as a protective factor. This may be another example of a changing re- lationship between a risk or protective factor and body image. It is possible that non-aesthetic sports partic- ipation means something different to younger girls than to adolescents. Currently, we do not have enough data to definitively document developmental changes in this relationship much less the basis for those changes.

While first graders are capable of social com- parison, older children engage in the process much more frequently (Smolak, 1999). Social comparison may well be an important mediator in the develop- ment of body esteem (e.g.Stormer & Thompson, 1996). Similarly, self-esteem becomes more differ- entiated with age (Harter, 1986). Self-esteem is also more likely to suffer as social comparison becomes a more powerful source. Thus, the mediating roles of social comparison and self-esteem, as well as the relationship between them, may change as children develop.

Developmental considerations have not yet been adequately addressed in the body image literature. Indeed, in some areas we have virtually no data concerning the developmental changes in risk or pro- tective factors. There are even relatively few data available on the nature of changes in body image it- self, particularly if one wishes to examine either the components of body image or the differences in body image development by ethnicity, gender, or culture. Such information will be critical to the development of effective prevention and treatment programs.

What is the role of gender in body image development?

Body image is a strongly gendered phenomenon. In the past, a statement like this has often been inter- preted as meaning that boys and men do not have body image problems. This is clearly not true. Nonetheless, it is evident that the nature, risk factors, outcomes, and probably the developmental course of body dissatis- faction differ by gender. While it is important to iden- tify gender differences in patterns in the development of body image, it is probably more crucial to work toward …

,

Available online at www.sciencedirect.com

Cognitive and Behavioral Practice 18 (2011) 5–15 www.elsevier.com/locate/cabp

Integrating Motivational Interviewing and Cognitive Behavioral Therapy in the Treatment of Eating Disorders: Tailoring Interventions to

Patient Readiness for Change

Josie Geller, St. Paul’s Hospital, Vancouver, and University of British Columbia Erin C. Dunn, St. Paul’s Hospital, Vancouver

1077 © 20 Publ

This paper focuses on the integration of Motivational Interviewing (MI) and cognitive behavioral therapy (CBT) in the treatment of eating disorders. Although CBT is regarded as the treatment of choice in this population, it nevertheless has limitations: some patients fail to engage, drop out from treatment prematurely, or simply do not improve. These are common problems in a population characterized by high levels of ambivalence about change. MI strategies can assist clinicians in enhancing readiness for change, tailoring interventions to patient readiness status, and maintaining a therapeutic alliance throughout all stages of treatment. Preliminary research examining the efficacy of adaptations of MI in the treatment of individuals with eating disorders has been promising. This paper presents 4 patient scenarios involving individuals with varying degrees of readiness and in the context of different treatment settings. For each patient scenario, key issues are described and common roadblocks to developing or maintaining a therapeutic alliance are provided. Vignettes illustrate conversations between the patient and therapist for each scenario, highlighting how MI techniques can be integrated into CBT treatment and promote a working therapeutic relationship that enhances long-term treatment outcome.

MILLIONS of individuals every year are affected byeating disorders: anorexia ne

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