FINDING COMMON GROUND The 2nd Annual Australian Eating Disorders and Obesity Conference

This study aimed to evaluate a brief Cognitive Behavioural Therapy (CBT) group intervention program aimed at improving body image in women called “Positive Bodies: Loving the Skin You’re In”. A sample of 20 women aged 17 to 54 years, who volunteered to participate in this program, completed a questionnaire at the commencement and cessation of the intervention. The questionnaires, which aimed to monitor self-esteem and body image, consisted of the Rosenberg Self-Esteem Scale, the Body Areas Satisfaction Scale, the body shame and self-surveillance subscales from the Objectified Body Consciousness Scale and the Body Image Quality of Life Inventory. Paired samples t-tests, along with its nonparametric equivalent, were conducted in order to determine whether levels of self-esteem and body image variables improved from treatment commencement to cessation, as hypothesised. Results indicated that participants experienced a significant increase in selfesteem, body satisfaction and satisfaction with many specific body parts, along with a significant decrease in self-surveillance and body shame. In addition, a participant’s body image had a more positive effect on quality of life at treatment cessation in comparison to that at treatment commencement. Qualitative analyses also indicated that the program was well received by participants. Although analyses indicate that “Positive Bodies” might be associated with improved body image and self-esteem, limitations of the study must be considered when interpreting these results. An evaluation of “Positive Bodies: Loving the Skin You’re In”A Cognitive Behavioural Therapeutic based group program aimed at improving body image. Body image encompasses how an individual perceives and feels about their body, in addition to the degree to which they desire a body different to their own. People with negative body image experience strong negative affect and thoughts related to their bodies and may perceive their bodies in a distorted manner (Caddy & Richardson, 2012; Cash & Hrabosky, 2003; Peltzer & Pengpid, 2012). Furthermore, many use maladaptive behaviours to either minimize a discrepancy between their body and an ideal body or to minimize the distress experienced as a result of evaluating their bodies. Such experiences categorize negative body image (Dworkin & Kerr, 1987; Wade, George & Atkinson, 2009). Negative body image is observed frequently in women, and is observed to such a great extent that it is often considered a “normal” female trait. For example, Tiggeman and Pennington (1991; cited in Moulding, 2007) found that over half of a sample of Australian women was dissatisfied with their bodies. Although body image disturbance is most prevalent in adolescence and early adulthood (Matusek, Wendt & Wiseman, 2004), body image disturbance is also widespread amongst women of different ages (Teixeira et al., 2006). Western society and the media regularly endorse an unrealistic body ideal for women, which encourages women to have low body fat, particularly in the mid-section (Foster, Wadden & Vogt, 1997; Mautner, Owen & Furnham, 1999). It is not surprising, therefore, that many women feel the need to adhere to such an ideal and experience distress when their bodies differ from the ideal (Fursland et al., 2012; Hausenblas & Fallon, 2006; Moulding, 2007). Although body dissatisfaction can be partly attributed to the internalisation of these socio-cultural ideals that society and media endorse (Chen, Fox, Haase & Ku, 2010), the development of negative body image is complex. Parental weight concern, being teased as a child or as an adult for one’s appearance (Grilo & Masheb, 2005; Richardson & Paxton, 2010), engaging in frequent conversations about appearance and comparing one’s body with another (Mautner et al., 1999; Richardson & Paxton) and certain personality characteristics (Fursland et al.) are just some of the risk factors of negative body image that have been identified (Grilo & Masheb; Zabinski, Wilfley, Calfas, Winzelberg & Taylor., 2004). These risk factors are sometimes addressed in preventative or intervention measures for body image (Richardson & Paxton). In addition to the risk factors mentioned, self-esteem is of particular importance as it has been identified as a contributor to as well as a result of negative body image (Foster, Wadden & Vogt, 1997; Hawks, Madanat, Smith & de la Cruz, 2008; Mendelson, McLaren, Gauvin & Steiger, 2002). Aiming to improve and monitor self-esteem is particularly important for negative body image sufferers, as it has a large impact on the mental and physical health of an individual, has been found to be a greater predictor of eating disorders than dieting (Schmidt, 2001 cited in Karpowicz, Skarsater & Nevonen; 2009), and accounts for a large percentage of variance in body image dissatisfaction (Grilo & Masheb, 2005). Body image has even been shown to be improved through activities aimed at improving selfesteem (O’Dea & Abraham, 1999; Norwood, Murray, Nolan & Bowker, 2011) and conversely, self-esteem has been shown to be improved through activities and programs aimed at improving body image (Karpowicz et al.; Richardson & Paxton, 2010; Rosen, Reiter & Orosan, 1995). However, as the relationship between body dissatisfaction and self-esteem is bi-directional, negative body image also has a devastating effect on self-esteem (Dworkin & Kerr, 1987). Therefore, building self-esteem is often focused upon in body image improvement programs (Guinn, Semper, Jorgensen & Skaggs, 1997; Norwood et al.). In addition to low self-esteem, negative body image has also been found to contribute towards a number of other serious psychological and physical consequences (Grogan, Hartley, Connor, Fry & Gough, 2010). There is evidence to suggest that negative body image has been linked to development of depression, social anxiety (Stice, Hayward, Cameron, Killen, Taylor, 1999) smoking, low self-esteem and there has been speculation that negative body image even delays women’s psychosocial development (Grogan et al.; Harris, 1995; Mendelson et al., 2002). Furthermore, longitudinal studies have indicated that having a negative body image predisposes individuals to employing negative eating patterns such as calorie restriction, binge eating, purging or even subsequent eating disorders (Da Cunha Feio Costa, de Assis Guedes de Vasconcelos & Peres, 2010). These consequences indicate the serious impact that negative body image can have on the quality of life of an individual. The potential negative outcomes of body image disturbance highlight the importance of appropriate prevention and treatment for negative body image (Cash & Hrabosky, 2003). While only a small percentage of women develop eating disorders, a large percentage of women experience negative body image and are therefore at risk for negative mental and physical health outcomes (Tiggeman and Pennington, 1991 cited in Moulding, 2007). It is therefore important that body image interventions are not only designed for individuals suffering from eating disorders, but also for women with general body image problems (Gollings & Paxton, 2006; Moulding). The group program evaluated in the current study, “Positive Bodies: Loving the Skin You’re In” is a program based on Cognitive Behavioural Therapy (CBT) developed for women over the age of 16 with negative body image (see Lewis, 2012 for latest version of program in the form of a self help manual). CBT-based interventions are a popular choice for body image problems and have been proven to be effective in individual, group and computer-based or online formats (Cash & Hrabosky, 2003; Gollings & Paxton, 2006; Winzelberg, Taylor, Sharpe, Eldredge & Constantinou, 1997; Zabinski et al., 2004). The main aim of CBT is to teach individuals the relationships between their thoughts, behaviours and emotions and to modify maladaptive thoughts, behaviours and emotions which precipitate and maintain psychological issues (Rosen et al., 1995; Smith, Wolfe & Laframboise, 2001). Examples of CBT interventions have been successfully applied to individuals with body dysmorphic disorder (Rosen et al.), binge eating symptoms (Binford et al., 2005; Shelley-Ummenhofer & MacMillan, 2007), individuals with weight management issues (Rapoport, Clark & Wardle, 2000; Shelley-Ummenhofer & MacMillan) and individuals identified at risk of developing an eating disorder (Zabinski et al., 2004). Specifically, a CBT online course by Cash and Hrabosky (2003), which covers similar topics to “Positive Bodies”, reported improved self-esteem, decreased social anxiety and improved eating attitudes. The authors recommended that greater facilitator-client contact, as provided in “Positive Bodies”, could have encouraged clients to be more compliant with their program. Another individual CBT course aimed at improving body image over six weeks resulted in improved self-esteem, weakened maladaptive body image thoughts, improved affective body image, and clients judging their body size to be smaller and closer to the norm (Butters & Cash, 1987). Similarly, a CBT course of a psycho-educational nature run both online and in a group format, resulted in improved body image and unexpectedly resulted in improvements in anxiety and depression (Gollings & Paxton, 2006). Within a CBT framework, “Positive Bodies” aims to improve body image by covering a range of topics related to body image and wellbeing. For example, similar to other effective body image improvement programs and as recommended through literature, “Positive Bodies” aims to help clients reduce their thin-ideal internalization (Matusek et al., 2004; Robinson & Bacon, 1996; Stice, Marti, Spoor, Presnell, Shaw, 2008), gain acceptance of their bodies (Wade et al., 2009), identify contributors to their negative body image (Cash & Hrabosky, 2003; Richardson & Paxton), reduce their perceived pressure to be thin (Bucholz et al., 2008; Hawks et al., 2008), use relaxation techniques when experiencing anxiety of any kind (Caddy & Richardson, 2012) and improve their general health by improving their nutrition and increasing physical activity (Graff Low et al., 2006; Hausenblas & Fallon, 2006; Lock & Grange, 2005; Robinson & Bacon; Stice et al.). Furthermore, “Positive Bodies” aims to help clients build their self-esteem (Wolchik, Weiss & Katzman, 1986), become assertive in relation to appearance teasing and taking compliments (McVey, Davis, Tweed & Shaw, 2003; Robinson & Bacon) and develop adequate social support networks either through support from their peers in group interventions or from family and friends (Celio et al., 2000; Binford et al., 2005). Some of the programs which utilize these methods are based upon the CBT framework while others are based on different theoretical perspectives. A more detailed description of “Positive Bodies” and the activities it contains can be found within the method section. Although CBT strategies have been demonstrated to be effective with body image issues, and many of the specific strategies in “Positive Bodies” have been used in other efficacious programs, it is still imperative to evaluate the program. If “Positive Bodies” has the desired effect, participants should experience improvements in body image and selfesteem. As body image is multidimensional, a number of measures were assessed, including body surveillance; which measures how often a participant thinks about their body, body shame; which measures feelings of shame toward personal appearance, quality of life (QOL); which measures the impact that participants’ body image have on their quality of life, and body satisfaction. In addition, the current study will monitor self-esteem throughout the duration of the intervention. As in other body image programs, self-esteem activities have been incorporated into the “Positive Bodies” program due to the close relationship between body image and self-esteem discussed (Mendelson et al., 2002; Wolchick, Weiss & Katzman, 1986; Zabinski et al., 2004). In addition, prior studies demonstrated that CBT strategies have a positive effect on self-esteem in women with body image issues (Shelley-Ummenhofer & MacMillan, 2007), and evaluations of other body image-related programs have yielded concurrent improvements in body image and self-esteem (Cash & Hrabosky, 2003; Hawks et al., 2008; Karpowicz et al.,, 2009; McVey et al., 2003). Therefore, an improvement in self-esteem from baseline to post-treatment could therefore indicate “Positive Bodies” clients have responded well to self-esteem activities within the program or to other activities aimed at improving body image and general wellbeing. The aim of this study was to investigate whether participants reported improvements in self-esteem and body image in general from pre-treatment to post-treatment. It was hypothesized that an increase in self-esteem, body satisfaction and QOL would be observed, while a decrease in body surveillance and body shame was expected. It was also hypothesised, that due to “Positive Bodies” aiming to improve overall body image, participants’ satisfaction with different body parts would increase. A short qualitative analysis was conducted to explore participants’ perceptions of the program. EVALUATION OF BODY IMAGE PROGRAM 9 Method Participants The sample consisted of 20 women between the ages of 17 and 54 years (M=31.0, S.D =10.72) who volunteered to participate in the “Positive Bodies: Loving the Skin You’re In” program between 2008 and 2011.These women were a community self-referred sample. Measures The questionnaires in the current study consisted of a variety of scales to measure body image related constructs and self-esteem (Appendix A and B). In order to match preand postquestionnaires while maintaining participants’ survey responses confidential, participants were asked to create a unique re-identifying code. This code consisted of the first three letters of their first pet’s name and the last 3 numbers of their phone number. Demographics Participants were asked for general information, including their gender, age and reason for participating in the “Positive Bodies” group. The Rosenberg Self-Esteem Scale (RSES) (Rosenberg, 1965) was used, which measures global self-esteem in people of a variety of ages and cultures (Schmitt & Allik, 2005). This scale consists of 10 items, with four response categories (“Strongly Disagree” (1) to “Strongly Agree” (4)). A higher score is indicative of higher levels of self-esteem and an example of an item includes “On the whole I am satisfied with myself”. The internal consistency of the self-esteem scale in the current study was high (.92 and .87) and similar to that found in earlier studies (.92; Rosenberg, 1979). Rosenberg (1979) has also reported the RSES as having excellent test-retest reliability over a period of 2 weeks (.85 and .88) and Sinclair et al., (2010) reported appropriate convergent validity and discriminate validity. Many studies have indicated that this scale is bi-dimensional, although a meta-analysis (Huang & Dong, 2012) has indicated that these factors are most likely a result of negative and positive wording and do not measure different constructs. Therefore, in accordance EVALUATION OF BODY IMAGE PROGRAM 10 with the recommendations made by Huang and Dong, self-esteem will be treated as having one factor in the current study. The Body Areas Satisfaction Scale (BASS) was taken from the Multidimensional BodySelf Relations Questionnaire (Cash, 2000) and was used to measure body satisfaction. This scale requires the respondent to indicate how satisfied or dissatisfied they are with nine aspects of their appearance; for example, “face”, or “mid torso”, on a five point scale (“Very dissatisfied” (1) to “Very satisfied” (5)). A higher score is indicative of greater satisfaction with more areas of the body. Cash (1994) reported the BAS has adequate test-retest reliability (.86) and internal consistency of .77. In the current study, internal consistency was high (.93 and .85). The Objectified Body Consciousness Scale (McKinley & Hyde, 1996) consists of three subscales, two of which were selected for the current study; self-surveillance (8 items) and body shame (7 items). The self-surveillance scale measures how often a participant thinks about their body appearance, while body shame measures feelings of shame toward personal appearance. An example of an item in the self-surveillance and body shame scales are “I rarely think about how I look” and “I feel like I must be a bad person when I don’t look as good as I could” respectively. McKinley & Hyde reported adequate internal consistencies for the Surveillance Scale, .79 and .76 and for the Body Shame Scale, .84 and .70 for undergraduates and middle-aged women respectively. In the current study, the internal consistency of body surveillance was adequate (.81 and .88) while internal consistency for body shame was not. After deleting one item, the internal consistency rose (.88 and .83). These scales have been found to have convergent validity by having strong relationships with body-esteem and other measures of body image, and accounting for significant variance in dieting and restricting eating (McKinley & Hyde, 2006). Furthermore, body shame has also been validated as a measure of internalisation. The Body Image Quality of Life Inventory (Cash, 2002) was used in order to measure the impact that a participant’s body image has on their quality of life. This scale consists of nineteen EVALUATION OF BODY IMAGE PROGRAM 11 items, with seven response categories (“Very Negative Effect” (-3) to “Very Positive Effect” (+3)). The respondent is required to indicate what effect their body image has in different situations, such as, “My experiences when I meet new people”. A higher score on this scale indicates a participant’s body image has more of a positive impact. Cash and Fleming (2002) demonstrated that the scale had adequate test-retest reliability for a two to three week period (.79). In addition, Cash and Fleming also found adequate convergent validity, finding that scores were associated with higher body satisfaction, less body shame, lower body surveillance and less strongly internalized cultural beauty standards. The internal consistency for this sample was high (.914 and .948). Open Ended Questions were asked in the last section, in order to investigate whether participants believed they benefited from “Positive Bodies”, whether the program met their expectations and what they believed was the most useful aspect of the program. These responses were grouped and coded accordingly for analyses. Procedure: The current study is based on secondary data obtained from an unpublished dissertation conducted by Patrick (2011). The use of this secondary data was also approved by the University of Canberra’s Human Research Ethics Committee (HREC) in early 2012. This procedure section outlines the research method used in their studies. The body image program was advertised at the University of Canberra and local community websites for women who had concerns about their appearance (Advert found at Appendix C). Individuals interested in participating contacted the group facilitators via phone or email to register. Throughout this contact, group facilitators ensured participants were aware that a research project was being conducted to evaluate the program and that participation in this project was completely voluntary. The researchers attended the first session of the program to explain the study, what participation would involve and that a participant’s decision to refuse participation or withdraw from the study would not impact upon their group therapy or their relationship with their group EVALUATION OF BODY IMAGE PROGRAM 12 facilitator. Once informed consent was obtained, questionnaires were administered to the participants. Participants were allowed time to complete the questionnaires, and all questionnaires; either complete or incomplete, were provided to the researcher in a sealed envelope. During the last session (Session 6), the researcher administered the post treatment questionnaire in a similar manner described for the pre-treatment questionnaire. The group facilitators were a number of Clinical Masters Students and were frequently supervised by the creator of the program, Dr Vivienne Lewis, to ensure the group was facilitated in an ethical manner and that the program manual was adhered to. Intervention: The intervention evaluated in the current study consisted of six 1.5 hour group sessions, over six weeks. “Positive Bodies: Loving the Skin You’re In” was designed by body image expert, Dr Vivienne Lewis (see Lewis 2012 for self help manual converted from program), and is based on Australian and International research on effective intervention techniques for body image concerns. Importantly, that the manual outlining “Positive Bodies” was published in 2012, but the program itself was developed before the study began in 2008. Through group discussion, the course covers the development of body image, eating disorders and risky behaviours, healthy eating and behaviours, methods to challenge negative thoughts about one’s body, using relaxation and body awareness to increase positive thoughts about one’s body, and how to increase self-esteem. The course also discusses how to detect and act upon negative body image in children. A general outline of the “Positive Bodies” program which was utilised in the current study is provided below. Session 1: Group members create group rules and personal goals for the therapy. The meaning of body image and examples of the cognitive, emotional, physical and attitudinal aspects of body image are discussed. Furthermore, participants are encouraged to discuss the many negative consequences of body image. These discussions commonly cover how negative body esteem EVALUATION OF BODY IMAGE PROGRAM 13 compromises self-esteem, gender identity and sexual fulfilment, while contributing to interpersonal anxiety, depression and eating disturbances. Session 2: Risk and maintenance factors for negative body image are discussed. For example, participants are asked to identify some cultural (e.g. media and society), interpersonal (e.g. teasing and relationships with others), and personality (e.g. perfectionism) influences that have and are contributing to maintenance of their negative body image. Group facilitators then explain how negative thinking also contributes to the maintenance of negative body image using the ABC theory. This theory explains a specific situation (A) triggers certain thoughts or beliefs about your body (B) resulting in an emotional or behavioural consequence (C). Session 3: The impact of having common appearance assumptions and body image distortions are discussed and demonstrated by the facilitators, with an example of a story of female twins that have different body image. Following on from this story, participants identify which common appearance assumptions they possess and the common body image distortions they experience. Group facilitators explain how group members can dispute associated negative automatic thoughts about their bodies, by adding two additional steps (Disputing and Effects of Disputing automatic thoughts) to the ABC method described above. Group members are taught the importance of having positive body affirmations and are given the opportunity to write some affirmations and say them aloud. Session 4: Eating disorders and maladaptive eating patterns are discussed. For example, facilitators explain how common maladaptive methods; such as laxative use and purging, are not only damaging to the human body, but also do not necessarily prevent weight gain. Group members discuss how to improve their nutrition and exercise patterns. Facilitators teach methods to decrease the use of body image rituals, such as checking, pinching and re-dressing, and the use of such methods are planned for homework. EVALUATION OF BODY IMAGE PROGRAM 14 Session 5: This session focuses on managing stress and building self esteem. Participants are encouraged to think of practical ways they could improve their self-esteem and plan to use such methods outside of the group intervention. In addition, group members discuss the benefits of relaxation and mindfulness and how they can incorporate these methods into their lives. Participants are also encouraged to participate in grounding, breathing, meditation and mindfulness exercises insession in order to identify which method they like and are likely to use outside of the sessions. Session 6: Group members discuss how to be assertive and how to respond to inattentive (people who do not provide the compliments wanted), insensitive (people who provide criticism of one’s appearance) and intimidating (looks are perceived as intimidating) people. Group members then review the content of the workshop and set specific, measurable, attractive, realistic and timed (SMART) goals for the future. Participants conclude their workshop by writing a letter to their body, which is a powerful exercise. This activity allows participants to apologise to their bodies for the way they have mistreated it in the past, thank their body for all that it has given them, and to promise their bodies that they will attempt to treat them better in the future. Results All statistical analyses used a critical alpha level of .05, using SPSS 17.0. In order to deal with missing cases, list-wise deletion was used throughout analyses. Descriptives of Self-Esteem and Body Image Variables Descriptive statistics for all variables included in analyses can be found in Table 1 and 2. Inspection of the mean scores at pre-treatment revealed that the sample’s average responses on selfesteem items were neutral (between mostly disagree and mostly agree), and that the average response to the body satisfaction items were in the “neither satisfied nor dissatisfied” range. Furthermore, the average response on the self-surveillance and shame items were in the “somewhat EVALUATION OF BODY IMAGE PROGRAM 15 agree” range, indicating participants were experiencing some body shame and were engaging in some self-surveillance. The QOL mean indicated that body image, on average, was having at least a slight negative effect on the quality of life of participants. These average responses were different post-treatment, with the average response on the self-esteem items in the “mostly agree” range, demonstrating participants were experiencing higher levels of self-esteem post-treatment. Post-treatment, average responses on self-surveillance were in the “neither disagree nor agree” range, and for body shame in the “slightly disagree range”, which indicated decreases in body shame and self-surveillance. The QOL mean post-treatment indicated that participants’ body image had a slight positive effect on quality of life post-treatment. Participants pre-treatment were found to be dissatisfied with their lower-torso, mid-torso, muscle tone and weight, whereas post-treatment participants were only dissatisfied with their weight. While participants were only satisfied with height at pre-treatment, at post-treatment participants were also satisfied with their face, hair and overall appearance. Although the mean scores demonstrate improvements in all variables, inspection of the range of scores reveal some concerning scores not only at pre-treatment, but also at post-treatment. For example, minimum scores indicated that there were participants that endorsed “Strongly Disagree” on nearly all items of self-esteem at pre-treatment, and “Mostly Disagree” on nearly all items at post-treatment. Similarly, there were participants who on average responded, “Very Dissatisfied” on items measuring satisfaction with different aspects of their appearance at pretreatment and “Mostly Dissatisfied” at post-treatment on the same scale. In regards to shame, there was participants that on average responded “Strongly Agreed” to shame items at pre-treatment, and responded on average, “Somewhat Agreed” to body shame items at post-treatment. Of additional concern, QOL revealed that at pre-treatment body image was having a “Very Negative Effect” on the quality of life of a participant and still was having a negative effect on a participants’ quality of life at post-treatment. EVALUATION OF BODY IMAGE PROGRAM 16 Table 1 Descriptives of Body Image and Self-Esteem variables Scale N Minimum Maximum Mean Std. Deviation Pre Self-Esteem 20 11.00 37.00 25.10 6.46 Post Self-Esteem 20 20.00 38.00 29.95 4.88 Pre Body Satisfaction 20 9.00 39.00 24.30 8.23 Post Body Satisfaction 20 17.00 43.00 29.25 5.57 Pre Self-surveillance 20 18.00 56.00 39.10 9.34 Post Self-surveillance 20 14.00 44.00 31.60 8.04 Pre Body shame 20 8.00 41.00 27.60 9.06 Post Body shame 20 7.00 32.00 20.70 6.78 Pre Quality of Life 20 -65.00 21.00 -20.90 26.82 Post Quality of Life 20 -30.00 35.00 4.60 20.49 *Pre = Pre-treatment, Post = Post-treatment EVALUATION OF BODY IMAGE PROGRAM 17 Table 2 Descriptives of Items on the Body Areas Satisfaction Scale Scale N Minimum Maximum Mean Std. Deviation Pre Satisfaction Face 20 1.00 5.00 3.20 1.00 Post Satisfaction Face 20 2.00 5.00 3.85 0.67 Pre Satisfaction Hair 20 1.00 5.00 3.30 1.30 Post Satisfaction Hair 20 2.00 5.00 3.80 0.77 Pre Satisfaction Lower Torso 20 1.00 4.00 2.28 1.07 Post Satisfaction Lower Torso 20 1.00 5.00 2.65 1.14 Pre Satisfaction Mid Torso 20 1.00 4.00 2.15 1.04 Post Satisfaction Mid Torso 20 1.00 5.00 2.40 0.94 Pre Satisfaction Upper Torso 20 1.00 4.00 2.55 1.09 Post Satisfaction Upper Torso 20 2.00 5.00 3.30 0.86 Pre Satisfaction Muscle tone 20 1.00 4.00 2.15 1.04 Post Muscle tone 20 1.00 5.00 3.15 0.99 Pre Satisfaction Weight 20 1.00 4.00 2.20 1.24 Post Satisfaction Weight 20 1.00 4.00 2.45 1.09 Pre Satisfaction Height 20 1.00 5.00 3.80 1.16 Post Satisfaction Height 20 3.00 5.00 4.10 0.64 Pre Satisfaction Overall Appearance 20 1.00 4.00 2.68 1.15 Post Satisfaction Overall Appearance 20 1.00 5.00 3.55 0.94 *Pre = Pre-treatment, Post = Post-treatment EVALUATION OF BODY IMAGE PROGRAM 18 Change in Body Image and Self-Esteem from Pre-treatment to Post-treatment A number of Paired Samples T tests were planned in order to investigate whether participants’ body image and self-esteem improved from pre-treatment to post-treatment. During assumption testing however, QOL, body satisfaction and satisfaction with certain body parts were found to have non-normal distributions, which violated the assumptions of these tests. Normally, t-tests are robust to violations of normality with samples over thirty. However, as the sample size was small a decision was made to use Wilcoxon Signed Rank Tests, the non-parametric equivalent of a paired samples t test, with variables with non-normal distributions. Changes in Body Image and Self-Esteem Three paired samples t-tests were conducted to determine whether participants’ self-esteem increased, and participants’ body shame and body surveillance decreased from pretreatment to posttreatment. As expected, there was a significant increase in self-esteem from pretreatment (M = 25.10, SD = 6.46) to post-treatment (M = 29.95, SD = 4.88), t(19) = 4.66, p<.001. The eta squared statistic (.53) indicated a large effect size. In addition, as hypothesised, there was a significant decrease in self-surveillance from pretreatment (M = 39.10, SD = 9.34) to post-treatment (M = 31.60, SD = 8.04), t(19) = 3.749, p =.001 and in body shame from pre-treatment (M = 27.60, SD = 9.05) to post-treatment (M = 20.70, SD = 6.77), t(19) = 4.191, p <.001. These eta statistics for both these analyses indicated large effect sizes (.425 and .48 respectively). Two Wilcoxon signed rank tests were conducted in order to investigate whether participants’ body satisfaction and QOL increased from pre-treatment to post-treatment. These tests revealed a significant increase in body satisfaction following participation in “Positive Bodies”, z = -3.34, p = .001, with a large effect size (r = .53). The median score on the BSAS increased from pre-program EVALUATION OF BODY IMAGE PROGRAM 19 (Md = 26) to post-program (Md = 30). An increase in QOL was also observed, z = 3.44, p = .001, with a large effect size (r = .54). These tests indicate a favourable outcome from pre-treatment to post-treatment in increases in self-esteem, body satisfaction and the extent to which body image has a positive impact on participants’ QOL, while experiencing decreases in body shame and body surveillance. Changes in Satisfaction with Body Parts For individual parts, paired samples t tests indicated that there was a significant increase in participants’ satisfaction with their face from pre-treatment (M = 3.20, SD = 1.01) to post-treatment (M = 3.85, SD = 0.67), t(19) = 3.32, p =.004 and with their muscle tone from pre-treatment (M = 2.15, SD = 1.04) to post-treatment (M = 3.15, SD = 0.99), t(19) = 4.359, p <.001. Eta squared statistics indicated a large (.367) and moderate (.096) effect size respectively. No significant difference in satisfaction with mid-torso from pre-treatment (M = 2.15, SD = 1.04) to post-treatment (M = 2.40, SD = 0.94), t(19) = 1.422, p = .171, was observed. Wilcoxon Signed Rank Tests were conducted with the variables which violated the assumption of normality (See Table 3). These tests indicated that participants’ satisfaction with their hair, lower torso, upper torso and overall appearance significantly increased from pre-treatment to posttreatment. No significant differences were found for satisfaction with weight and height. EVALUATION OF BODY IMAGE PROGRAM 20 Table 3 Z scores, P values, Effect Sizes and Median Scores for Items on the Body Areas Satisfaction Scale Variable Z score P value R (effect size) Median score T1 Median Score T2 Hair -2.308 .021 0.364, medium 4.00 4.00 Lower Torso -2.124 .034 0.394, medium 2.00 2.00 Upper Torso -3.095 .002 0.489, medium 2.50 3.00 Weight -1.008 .313 0.159, small 2.00 2.00 Height -0.966 .334 0.159, small 4.00 4.00 Overall Appearance -2.953 .003 0.467, medium 3.00 4.00 Participants’ perceptions of the body image course Qualitative analyses were also conducted in order to assess which aspects of “Positive Bodies” the participants deemed useful and whether “Positive Bodies” met their expectations. A previous researcher coded participants’ responses to two separate questions “Please comment on whether the program met your expectations” and “What was the most useful aspect of the program?. These responses were then grouped by code and frequencies were conducted. Nine participants (45%) said that program met expectations, while 50% indicated the program exceeded expectations (50%). Twenty per cent reported the group discussions and sharing the experiences were the most useful aspects, while 80% indicated that strategies learnt throughout the intervention were the most useful aspects. EVALUATION OF BODY IMAGE PROGRAM 21 Discussion A sample of twenty women completed two questionnaires as part of an evaluation of the “Positive Bodies: Loving the Skin You’re In” program, which is a CBT based program aimed at improving body image (Lewis, 2012). These questionnaires were administered to investigate whether the participants experienced improvements in body image and selfesteem from the commencement to the cessation of the program. In order to investigate whether participants’ satisfaction with specific parts of their bodies improved from pre-treatment to post-treatment, participants’ responses on the BAS were compared over time. In line with the hypotheses and the aims of the program, participants became increasingly satisfied with a number of body features; including their face, muscle-tone, hair, lower torso, upper torso and overall appearance from baseline to post-treatment. This is a favourable outcome, as it could indicate that the strategies taught in “Positive Bodies” generalize to most body features and overall appearance. This is in line with research that has indicated that CBT-based strategies are applicable to people dissatisfied with a range of different body areas (Butters & Cash, 1987). In contrast, participants were not observed to become more satisfied with their midtorso, weight or height. The lack of improvement in satisfaction with height is not of concern, as participants indicated they were satisfied with their height at pre-treatment and this level of satisfaction was maintained at post-treatment. The results revealing that satisfaction with weight and mid-torso are concerning however, and may indicate that “Positive Bodies” should incorporate more activities aimed at improving satisfaction with these specific body areas. This result may have been obtained because the ideal body frequently endorsed by Society and the media, encourages women to have minimum body fat especially around the mid-torso. This social ideal may have resulted in dissatisfaction in weight and mid-torso EVALUATION OF BODY IMAGE PROGRAM 22 becoming more ingrained in comparison to other body areas, and therefore more difficult to improve in interventions. As hypothesised, from pre-treatment to post-treatment, participants’ self-esteem also significantly improved, with a large effect size. This is a very encouraging result as it may indicate that individuals are experiencing improvements in self-esteem either as a direct result of the self-esteem activities or indirectly through activities aiming to improve body image or general wellbeing. This is an important outcome, particularly because people with higher self-esteem fare better physically and mentally than those with lower-self-esteem (O’Dea & Abraham, 1999). This is in line with previous research which indicates that CBT strategies were successful in increasing self-esteem in women with body image problems (Dworkin & Kerr, 1987) and that concurrent improvements were observed for self-esteem and body image throughout body image interventions (Cash & Hrabosky, 2003; Hawks et al., 2008; Karpowicz et al., 2009; McVey et al., 2003). The main aim of “Positive Bodies” was to improve participants’ body image. Various measures of body image were administered in order to monitor the overall body image of the participants through treatment. Participants’ ratings on all body image measures improved largely and significantly from pre-treatment to post-treatment. Therefore, participants’ reported thinking less about their bodies, experiencing less shame towards their physical appearance, experiencing greater body satisfaction and reported experiencing a slight positive effect of body image on QOL at post-treatment. These results coincide with the hypotheses and previous research which indicate that CBT-based interventions are effective in improving body image by reducing maladaptive body image thoughts, affect and behaviours and by teaching individuals to perceive their bodies in a more objective manner (Rosen et al., 1995; Smith et al., 2001). Of particular importance, body image had a slight positive effect on EVALUATION OF BODY IMAGE PROGRAM 23 participant’s QOL at post-treatment. This could indicate that for the overall sample, body image problems no longer impacted negatively on other aspects of participants’ lives; such as their relationships with others, daily activities, sexuality and satisfaction with life in general. It should be noted, however, that post-treatment levels in body image variables are still not ideal, and therefore, “Positive Bodies” may need to be amended in order to produce greater changes in body image. Participants’ ratings on popular measures of body image and wellbeing might be important, but their perceptions of the program can provide equally important information about the utility of the program (Banasiak, Paxton & Hay, 2007). Qualitative analyses indicated that participant’s had a positive perception of the program, as 95% said “Positive Bodies” met or exceeded their expectations. In addition, 80% indicated that the strategies taught were the most useful aspects of “Positive Bodies”. This is in line with research indicating that CBT strategies are relevant for body image issues (Cash & Hrabosky, 2003; Gollings & Paxton, 2006; Winzelberg et al., 1997; Zabinski et al., 2004) and that clients appreciate learning strategies to combat negative body image as simply providing information regarding body image and eating disorders is not sufficient for change (Banasiak et al.; Cash & Hrabosky). In addition, 20% of the sample indicated group discussions and sharing experiences were the most useful aspects of the program. This is in accordance with research which indicates that group interventions are practical because individuals can feel a strong sense of support from other individuals experiencing negative body image (Rosen et al.1995; Zabinski, 2004) and can demonstrate their understanding of principles via discussion with group members, which also increases adherence to intervention procedures (Wade et al.,