Journal of Rational-Emotive & Cognitive-Behavior Therapy
Volume 15, Number 4, Winter 1997
COGNITIVE-BEHAVIORAL BODYIMAGE THERAPY: EXTENDED
EVIDENCE OF THE EFFICACY OF A
SELF-DIRECTED PROGRAM
Thomas F. Cash
Old Dominion University
Danielle M. Lavallee
Virginia Consortium Program in Clinical Psychology
ABSTRACT: Scientific investigations support the effectiveness of cognitivebehavioral therapy (CBT) in the treatment of body dissatisfaction across a
range of populations. Grant and Cash (1995) used CBT with 23 extremely
body-dissatisfied women and found equivalent and successful outcomes for
body-image CBT administered in group therapy versus a self-directed format
with only modest therapist contact. The present study compared Grant and
Cash's data with those of an equally body-dissatisfied sample (n = 12)
treated via Cash's (1995) CBT self-help book administered with minimal professional contact. The latter program produced significant improvements in
body image and adjustment, without changes in body weight. Outcomes and
levels of compliance were equivalent to those that Grant and Cash had found
under conditions involving greater degrees of professional contact. The study's
limitations and its scientific, clinical, and ethical implications for the use of
body-image CBT are discussed.
The contemporary construct of body image refers to attitudes and
perceptions regarding one's own physical characteristics, particularly
one's appearance (Cash & Pruzinsky, 1990). Approximately 40% to
50% of women and about one-fourth of men in our society report overThe authors are grateful to Jill R. Grant and Antonia Straight for their contributions to this
research.
Address correspondence to Thomas F. Cash, Ph.D., Department of Psychology, Old Dominion
University, Norfolk, VA 23539-0267 or by e-mail to [email protected].
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C 1997 Human Sciences Press, Inc.
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Journal of Rational-Emotive & Cognitive-Behavior Therapy
all body dissatisfaction (Cash & Henry, 1995; Cash, Winstead, &
Janda, 1986; Muth & Cash, 1997). A "negative body image" can predispose and maintain eating disorders (Cash & Brown, 1987; Cash &
Deagle, 1997; J. C. Rosen, 1990), depression (Cash & Szymanski, 1995;
Noles, Cash, & Winstead, 1985), as well as social-evaluative anxiety,
sexual difficulties, and poor self-esteem (Cash, 1990; Hangen & Cash,
1991; Pruzinsky, 1990). The DSM-IV (American Psychiatric Association, 1994) also diagnostically recognizes body dysmorphic disorder
(BDD) as an intense and persistent experience of "imagined ugliness"
(Phillips, 1996; Rosen, 1995).
Cognitive-behavioral therapies (CBT) have been developed to help
people overcome body-image disturbances (Cash, 1996; Cash & Grant,
1996; Freedman, 1990; J. C. Rosen, 1995; J. C. Rosen & Cash, 1995).
Several published investigations attest to the success of body-image
CBT relative to various control conditions in the treatment of averageweight, body-dissatisfied women without eating disorders (Butters &
Cash, 1987; Dworkin & Kerr, 1987; Fisher & Thompson, 1994; J. C.
Rosen, Saltzberg, & Srebnik, 1989). In most studies, body-image CBT
was conducted in a group-therapy format for 6 to 12 weekly sessions.
Body-image improvements with CBT have been found to surpass the
negligible effects of repeated assessments (by no-treatment or wait-list
controls) as well as the sometimes modest benefits of minimal or supportive therapies. Rosen and his colleagues further confirmed the efficacy of body-image CBT with obese persons (J. C. Rosen, Orosan, &
Reiter, 1995) and with clinical BDD patients (J. C. Rosen, Reiter, &
Orosan, 1995). Collectively, these studies have indicated that bodyimage gains persist at follow-ups of several months and generalize to
improved psychosocial adjustment.
Most psychotherapists regularly suggest or prescribe self-help books
and materials to their clients (Pantalon, Lubetkin, & Fishman, 1995;
Santrock, Minnett, & Campbell, 1994). Meta-analytic evidence points
to the success of self-administered treatments with minimal to modest
therapist contact (Gould & Clum, 1993; Marrs, 1995; Scogin, Bynum,
Stephens, & Calhoon, 1990). In 1991, Cash published an audiocassette
body-image CBT program for use in self-directed, therapist-guided formats. Grant and Cash (1995) compared two modalities of managing
this self-directed program: (1) the inclusion of weekly 90-minute group
body-image CBT, versus (2) only 20 minutes of weekly face-to-face contact with an assistant who encouraged and reviewed the completion of
assigned homework. The results indicated that group and modest-contact modalities were equally effective in producing statistically and
Thomas F. Cash and Danielle M. Lavallee
283
clinically significant changes in body image and psychosocial functioning. This finding is provocative in view of plausible arguments that
CBT self-help procedures would be most effective if systematically
managed within the context of ongoing therapy (Pantalon et al., 1995).
The purpose of the present research was to extend Grant and Cash's
(1995) study and compare its outcomes and those of a minimal-contact
body-image CBT program. The latter was a 10-week, 8-step bibliotherapeutic format, using Cash's (1995) self-help book What Do You
See When You Look in the Mirror?: Helping Yourself to a Positive Body
Image. The book's procedural content is quite similar to that of Cash's
(1991) audiocassette program administered by Grant and Cash (1995).
The only contact with participants during the minimal-contact condition was a brief weekly telephone conversation with an assistant, who
merely asked about progress in completing homework and offered encouragement to carry out as many of the assignments as possible. Unlike the Grant and Cash (1995) study, however, homework was not
reviewed.
METHOD
Participants
The 23 recipients of Grant and Cash's (1995) body-image treatments
were volunteers recruited through a mass testing of college women at
Old Dominion University. Selection criteria included: (a) a very negative body image, defined by extreme scores on standardized body-image assessments (described below); (b) the absence of anorexia or bulimia nervosa; (c) depressive symptomatology below a cut-off score of
24 on the Beck Depression Inventory (Beck & Steer, 1987); (d) body
weight within 25% of an actuarial norm. Participants averaged 24
years of age.
A somewhat less stringent selection procedure was followed for the
minimal-contact condition to approximate the population of persons
who would choose a self-help modality for body-image improvement.
By posted announcements of the program and a brief telephone conversation with those expressing interest, eligibility was defined as
having negative thoughts and feelings about aspects of one's physical
appearance to the extent that the experiences are distressing, interfere with the quality of day-to-day life, and impair self-esteem. It was
explained that the program was not intended as a treatment per se for
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Journal of Rational-Emotive & Cognitive-Behavior Therapy
either severe depression or eating disorders. Sixteen volunteers (13
women and 3 men), who were 17 to 53 years of age (M = 26), met the
self-defined criteria and completed initial assessments.
Assessment Procedures
The following measures from the Grant and Cash (1995) treatment
study were completed by minimal-contact participants at pre- and
posttreatment. Five body-image measures tapped the evaluative, investment, and affective components of body-image attitudes (Cash,
1994a). The two adjustment measures assessed symptoms of depression and eating disturbance.
Multidimensional Body-Self Relations Questionnaire (MBSRQ). The
69-item MBSRQ assesses body-image attitudes (Brown, Cash, & Mikulka, 1990; Cash et al., 1986; Cash, 1994c) with 10 subscales. Three
subscales served as outcome indices. Appearance Evaluation assesses
evaluation of and satisfaction with overall appearance (Cronbach's alpha = .88). Appearance Orientation measures the degree of importance of and attention paid to one's appearance, as well as behavioral
efforts to maintain or improve appearance (alpha = .85). Overweight
Preoccupation (Cash, Wood, Phelps, & Boyd, 1991) taps weight vigilance, fat anxiety, current dieting, and eating restraint (alpha = .73).
Situational Inventory of Body-Image Dysphoria (SIBID). The SIBID
(Cash, 1994b) contains items describing 48 situations for which respondents indicate their frequency of negative body-image emotions
(from 0 = never to 4 = always or almost always). The situations include social and nonsocial contexts, exercising, grooming, eating, intimacy, physical self-focus, and appearance changes. The SIBID's mean
is a reliable (alpha > .90), stable (1-month r — .86), and valid index of
negative body-image affect.
Appearance Schemas Inventory (ASI). The ASI (Cash & Labarge, 1996)
assesses assumptions regarding the salience and meaning of one's
physical appearance in one's life. Its 14 statements are rated on a
l-to-5, disagree-agree scale (e.g., "The only way I could ever like my
looks would be to change what I look like"; "I should always do whatever I can to look my best"). Internally consistent ASI scores (alpha =
.84) have been found to predict dysfunctional body-image thoughts and
affect.
Thomas F. Cash and Danielle M. Lavallee
285
The Beck Depression Inventory (BDI). The 21-item BDI (Beck & Steer,
1987) measures past-week depressive symptoms, with an internal consistency of .88 for nonpsychiatric samples.
The Bulimia Test-Revised (BULIT-R). This 28-item revision of the original BULIT (Thelen, Farmer, Wonderlich, & Smith, 1991) is a reliable
(alpha = .97) and valid index of bulimic symptoms (i.e., binge eating,
experiences of eating dyscontrol, body-image concerns, and purgative/
compensatory behaviors such as vomiting, fasting, excessive exercise,
and use of laxatives or diuretics.
Assessments of Procedural Compliance and Utility, After the program,
all participants completed an inventory of the frequency of use, perceived helpfulness, and likelihood of future use of each procedure in
the program. Minimal-contact participants also took a 40-item multiple-choice test (alpha = .93) on the content of the self-help book.
Treatment Procedures and Conditions
Grant and Cash (1995) describe in detail the procedures employed in
the group and modest-contact modalities of body-image CBT. They
used Body-Image Therapy: A Program for Self-Directed Change (Cash,
1991), consisting of four 60-minute audiocassettes, a client's workbook,
and therapist's manual. Nearly identical in procedural content, Cash's
(1995) self-help book, What Do You See When You Look in the Mirror?:
Helping Yourself to a Positive Body Image, was assigned to minimalcontact participants. This 8-step program (see also Cash, 1996, 1997;
Cash & Grant, 1996) involves:
1. Self-assessment of historical, cultural, physical, and interpersonal influences in developing a negative body image.
2. Training in self-monitoring (diary-keeping) of body-image experiences
to identify their antecedent events, mediating cognitions, and emotional and behavioral consequences.
3. Relaxation training (muscle relaxation, diaphragmatic breathing,
guided imagery, and self-instruction) and desensitization with imaginal and mirror body-areas exposure, and imaginal exposure to precipitating situations and events.
4. Identification and disputation of 10 dysfunctional "appearance assumptions."
5. Self-monitoring of 12 cognitive body-image errors and cognitive restructuring to alter faulty internal dialogues.
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Journal of Rational-Emotive & Cognitive-Behavior Therapy
6. Self-assessment of avoidant and compulsive body-image behaviors
and the use of multiple strategies (e.g., exposure, response prevention, stress inoculation, covert rehearsal, and self-regulation) to decrease these maladaptive patterns.
7. Mastery-and-pleasure and self-affirming exercises to increase adaptive body-image behaviors and experiences.
8. Problem-solving, covert rehearsal, and assertion to manage troublesome interpersonal events and prevent relapse.
Minimal-contact participants had a 5- to 10-minute scheduled weekly
telephone conversation with the program assistant, who was a secondyear female doctoral student. She asked about and encouraged participants' compliance with assigned reading and homework activities. Unlike in the Grant and Cash (1995) study, homework was not submitted
or explicitly reviewed. All participants received a relaxation training
tape (Cash, 1991).
RESULTS
Preliminary Analyses of Attrition and Pretest
Differences
Whereas there was no attrition from the Grant and Cash (1995)
treatments, 4 of the 16 minimal-contact enrollees failed to complete
posttest assessments. Statistical pretest comparisons of the drop-outs
and completers revealed no reliable differences in their initial body
image, adjustment, or body mass index (BMI = kg weight/m2 height).
Two of the 4 drop-outs made an early decision to discontinue due to
excessive school or work loads. The third drop-out had minimal bodyimage problems; the fourth reported that the program was "pushing
her too hard."
In the absence of differential outcomes between Grant and Cash's
(1995) modest-contact and group treatments, the two conditions were
combined and compared with the current minimal-contact intervention.
Because selection procedures varied somewhat between Grant and
Cash's (1995) treatments and the minimal-contact condition, possible
pretest differences were first examined on all dependent variables. Analyses of variance (ANOVAs) detected only one reliable difference. Participants' endorsement of dysfunctional appearance assumptions on the
ASI was stronger in the minimal-contact condition than in the Grant
and Cash (1995) treatments (Ms = 3.49 vs. 3.00), F(l, 33) = 7.42, p <
Thomas F. Cash and Danielle M. Lavallee
287
.01. No differences occurred on BMI. Furthermore, all minimal-contact
completers would have met Grant and Cash's (1995) psychometric selection criteria for body dissatisfaction.
Efficacy of Minimal-Contact Body-Image CBT
Because a repeated-measures multivariate analysis of variance
(MANOVA) confirmed significant changes (p < .008) for participants
in the minimal-contact condition, univariate ANOVAs were carried
out. As shown in Table 1, the body-image changes included more favorable appearance evaluations (p < .005), reductions in overweight preoccupation (p < .03), weakening of appearance investment on the ASI
(p < .02) and on the MBSRQ Appearance Orientation scale (p < .02),
and decreased experiences of situational body-image dysphoria on the
SIBID (p < .004). ANOVAs on the BDI and BULIT-R also revealed
significantly improved psychological adjustment, with fewer symptoms
of depression (p < .001) and eating disturbance (ps < .003).
To ascertain the clinical significance of body-image changes in the
minimal-contact condition, participants' "functional recovery" on Appearance Evaluation was examined. Functional recovery is reflected
by a posttest score that is closer to the mean of a normally functioning
than a dysfunctional population (Jacobson & Truax, 1991). Grant and
Cash (1995) found a functional recovery rate of 57% of clients in the
modest-contact CBT conditions. Using the same criterion, the recovery
for minimal-contact CBT was 75%. Whereas no completer of the minimal-contact treatment scored closer to the functional than dysfunctional norm at pretest, three-fourths did so at posttest.
Grant and Cash (1995) determined that the favorable outcomes
of body-image CBT were not attributable to any concurrent weight
changes. Similarly, for the minimal-contact condition, there were no
reliable changes in BMI from pretest (M = 25.0, SD = 5.3) to posttest
(M = 24.7, SD = 5.4), F(l, 11) = 2.24, p > .15.
Relative Efficacy of Minimal-Contact
Body-Image CBT
A comparison of the minimal-contact condition with the combined
Grant and Cash (1995) treatments was made by analyses of covariance (ANCOVA) of posttest scores adjusted for levels at pretest. As is
evident in Table 1, there were no significant effects of treatment condition on either body image or psychological adjustment. Furthermore,
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Journal of Rational-Emotive & Cognitive-Behavior Therapy
Table 1
Treatment Outcomes on Body-Image and
Adjustment Measures
Measure /
Condition
Pretest
M (SD)
Posttest
M (SD)
Appearance Evaluation (MBSRQ)
Grant & Cash
2.37a
2.95b
(0.51)
(0.61)
Minimal Contact
2.32a
3.25b
(0.82)
(0.60)
Body-Image Dysphoria (SIBID)
2.32a
Grant & Cash
1.48b
(0.72)
(0.71)
Minimal Contact
2.73a
1.81b
(0.46)
(1.01)
Overweight Preoccupation (MBSRQ)
Grant & Cash
3.48a
2.66b
(0.69)
(0.74)
Minimal Contact
3.46a
2.83b
(0.96)
(0.86)
Appearance Orientation (MBSRQ)
3.80a
Grant & Cash
3.42b
(0.49)
(0.33)
Minimal Contact
3.54b
4.00a
(0.54)
(0.67)
Appearance Schemas (ASI)
Grant & Cash
2.99a
2.55C
(0.51)
(0.57)
Minimal Contact
3.49b
2.71C
(0.53)
(0.92)
Depression (BDI)
Grant & Cash
11.61a
5.78b
(5.89)
(5.82)
Minimal Contact
17.42a
8.33b
(12.36)
(6.32)
Minimal
Contact
Pre-Post
(ANOVAs)
Posttest
Comparisons
(ANCOVAs)
11.89**
1.61
13.52**
<1
6.50*
<1
7.91*
<1
9.08**
<1
18.56**
<1
Thomas F. Cash and Danielle M. Lavallee
289
Table 1 (Continued)
Measure /
Condition
Pretest
M (SD)
Posttest
M (SD)
Eating Disturbance (BULIT-R)
Grant & Cash
62.09a
(18.65)
Minimal Contact
69.58a
(27.83)
46.96b
(15.53)
49.17b
(23.98)
Minimal
Contact
Pre-Post
(ANOVAs)
Posttest
Comparisons
(ANCOVAs)
14.56**
<1
Note. Grant and Cash's (1995) data are for combined group and modest-contact treatments. Differing row or column subscripts reflect significant mean differences. Although means shown
are unadjusted, posttest comparisons were on pretest-adjusted scores.
*p < .05 **p < .01
arguing against Type 2 error, only one F ratio exceeded 1.0 and the
adjusted mean differences were very small in magnitude and varied in
direction.
Evaluations of Treatment Compliance
and Perceived Utility
Treatments were compared on mean levels of reported compliance
with the assigned cognitive-behavioral components of the program. A
correlation between this index and performance on the test of knowledge of the program's content (r = .79, p < .002) evinced the validity
of reported compliance. On the 1 to 5 scale, a mean compliance for
minimal-contact participants of 3.0 did not differ from the 3.2 level for
Grant and Cash's (1995) treatments. Nor were there significant differences in perceived helpfulness of the components (Ms = 3.3 vs. 3.6,
respectively) or intentions of their future use (Ms = 3.3).
DISCUSSION
The prevalence of body-image dysfunctions in our society and their
relationship with clinical disorders and psychosocial well-being highlight the necessity of developing effective body-image interventions.
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Journal of Rational-Emotive & Cognitive-Behavior Therapy
Our results offer further confirmation of CBT's effectiveness in treating a negative body image. Previous outcome studies confirmed the
superiority of body-image CBT relative to no treatment as well as interventions involving only information and/or support (Butters &
Cash, 1987; Dworkin & Kerr, 1987; Fisher & Thompson, 1994; J. C.
Rosen et al., 1989). Most of these studies provided treatment in a
group-therapy modality. Grant and Cash (1995) recently found that
comparable success can be achieved when the program is implemented
in a largely self-directed format with modest face-to-face practitioner
contact. The present evidence points to equivalent treatment compliance and outcomes with the use of Cash's (1995) self-help body-image
CBT program plus brief monitoring and encouragement by telephone.
Clients' gains reflected improvements in all three facets of body-image attitudes—investment, evaluation, and affect (Cash, 1994a). After
CBT, clients had become less invested in their looks, more satisfied
with their bodies, less worried about being or becoming fat, and less
dysphoric across a range of situational contexts. A clinical significance
analysis indicated that 75% of the minimal-contact participants were
functionally recovered on Appearance Evaluation. Body-image CBT's
benefits also included reduced symptoms of depression and eating disturbance. All improvements occurred without concurrent changes in
body weight.
Several cautions must be heeded in understanding the present findings as promising but not definitive. First, there were differences in
selection procedures between conditions, even though this did not appreciably alter the composition of the samples on indices of body image
or psychological adjustment. Second, our study lacked a no-treatment
condition. However, all previous studies making this comparison confirmed the superiority of body-image CBT compared to the null effects
of repeated assessments with an untreated sample. Third, although
we observed reliable improvements, the size of the minimal-contact
sample was relatively small (n = 12) and reflected a 25% nonsystematic attrition rate. A more probing investigation of attrition from selfdirected body-image treatment is needed with larger samples. Some
authors (Gould & Clum, 1993; Pantalon et al., 1995) have speculated
that recipients of self-directed bibliotherapy regard a minimal-contact
requirement as unnecessary, intrusive, and annoying. Fourth, although
studies of body-image CBT with 1- to 5-month follow-ups (including
Grant & Cash, 1995) verified sustained gains, the maintenance of outcomes in the minimal-contact modality awaits further research.
Meta-analyses reveal the effectiveness of a variety of self-adminis-
Thomas F. Cash and Danielle M. Lavallee
291
tered treatments (Gould & Clum, 1993; Marrs, 1995; Scogin et al.,
1990). Even so, our findings do not necessarily imply similar success
from a purely self-help approach. The expectation and occurrence of
regular external monitoring may produce greater compliance and improvement than a completely autonomous use of the program. Nevertheless, body-image CBT has empirical support across various treatment modalities and degrees of therapist involvement. Given the
popularity and practical economy of self-help and the importance of
professional, ethical, and social responsibility (G. M. Rosen, 1993), future research must evaluate this program's utility without external
support, which represents the typical circumstances of consumer use.
Clients with body-image disturbances are likely to enter therapy
with a broad range of presenting complaints and difficulties. Certain
co-morbid or salient clinical disorders—such as major depression, anorexia nervosa, bulimia nervosa, social phobia, sexual dysfunctions,
body dysmorphic or severe personality disorders—may require professional therapy for their more extensive psychopathology. Within a
therapeutic context, however, the clinician can prescribe, monitor, and
manage the client's self-directed body-image CBT (Cash, 1996; Cash &
Grant, 1996; Pantalon et al., 1995). The detailed documentation of this
program further serves as a manual for practitioners' enhancement of
skills in assessing and treating body-image dysfunctions. The program
is now also available in a workbook format (Cash, 1997).
Current realities of managed mental-health care necessitate the efficient delivery of effective interventions, which may involve the systematic use of self-directed procedures. Useful guides exist for practitioners' selection and assignment of self-help materials (see Pantalon
et al., 1995; G. M. Rosen, 1993; Santrock et al., 1994). Ultimately, of
course, their efficacy should be evaluated empirically along a continuum of professional management.
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