Motivation and emotion/Book/2020/Body image flexibility

Overview
Traditionally, body image has been thought of as a continuum between negative and positive. Thinking of positive body image brings to mind someone who loves their body. However, contemporary theory frames positive body image as a more complex, multifaceted construct. Body image flexibility (BIF) is one important facet of this new conceptualisation of body image (Webb et al., 2015).

BIF is an individual's ability to experience internal events, including thoughts, emotions, sensations, and memories, about their body in the moment and in a non-judgemental way. Furthermore, it is the ability to choose to act consistently with one's values, even when faced with challenging body image events. BIF, therefore, serves as a method of emotional and behavioural regulation (Rogers et al., 2018). BIF differs from straightforward positive body image and other body image coping techniques in that it involves accepting negative feelings, rather than attempting to alter them. This distinction is important, as refraining from attempts to alter or suppress negative feelings is associated with better well-being (Rogers et al., 2018).

BIF was conceptualised by Sandoz et al. (2013) as a potential change process in the treatment of eating disorders. Since then, it also has been studied in relation to well-being, other aspects of body image, and eating disorder development and maintenance. The benefits associated with BIF include lower disordered eating, lower body dissatisfaction, lower psychological distress, higher body appreciation, and higher psychological flexibility (Rogers et al., 2018). Currently, there is a lack of research on how BIF can be developed. However, acceptance and commitment therapy (ACT) is emerging as an effective approach (Hill et al., 2020).

This chapter addresses:
 * What theoretical concepts are BIF based on and related to?
 * What does BIF have to do with eating disorders?
 * How does BIF benefit well-being?
 * How can BIF be improved by therapy?

 BIF can be measured using the Body Image Acceptance and Action Questionnaire (BI-AAQ) (Sandoz et al., 2013). Participants rate a series of statements based on how true they are, from 1 being never true and 7 being always true. The statements are:


 * 1) Worrying about my weight makes it difficult for me to live a life that I value.
 * 2) I care too much about my weight and body shape.
 * 3) I shut down when I feel bad about my body shape or weight.
 * 4) My thoughts and feelings about my body weight and shape must change before I can take important steps in my life.
 * 5) Worrying about my body takes up too much of my time.
 * 6) If I start to feel fat, I try to think about something else.
 * 7) Before I can make any serious plans, I have to feel better about my body.
 * 8) I will have better control over my life if I can control my negative thoughts about my body.
 * 9) To control my life, I need to control my weight.
 * 10) Feeling fat causes problems in my life.
 * 11) When I start thinking about the size and shape of my body, it's hard to do anything else.
 * 12) My relationships would be better if my body weight and/or shape did not bother me.

Theoretical basis of body image flexibility
BIF is a relatively recent concept in body image research, developed to facilitate understanding of adaptive responses to body image threats. It draws from the earlier conceptualisation of positive rational acceptance as a body image coping style, and from the broader theory of psychological flexibility (Rogers et al., 2018).

Positive rational acceptance
Cash et al. (2005) identified three styles of coping with threats to body image: avoidance, appearance fixing, and positive rational acceptance. Positive rational acceptance is an adaptive approach to affect regulation that involves engaging in rational self-talk and positive self-care. Positive rational acceptance differs from BIF in that it involves endorsing a positive reaction to body image threats, rather than neutral acknowledgement (Rogers et al., 2018). Examples of positive rational acceptance strategies include "telling myself I probably look better than I feel that I do" and "reminding myself that I will feel better after a while" (Cash et al., 2005). Using positive rational acceptance is associated with a number of psychological benefits, such as higher subjective well-being. Moreover, it has been shown to moderate the effects of body dissatisfaction on depression symptoms and well-being (Webb et al., 2015).

Psychological flexibility
BIF is a specific model grounded in broad psychological flexibility. Psychological flexibility was first formally conceptualised by the ACT model, and increasing flexibility is the overarching goal of ACT (Kashdan & Rottenberg, 2010). At its core, psychological flexibility involves openness to experience and committed behaviour. Firstly, it is the ability to accept the present moment and the feelings that arise from it. Secondly, it is the ability to behave in congruence with one's values, even when they are challenged in the present moment (Sandoz et al., 2013). Psychological flexibility allows individuals to be accepting of emotional experiences, be non-judgmentally aware of their inner selves, be willing to undergo distress in the pursuit of value-driven goals, and change behaviour or mindsets when they compromise their functioning or values (Kashdan & Rottenberg, 2010). Psychological flexibility is empirically supported as integral to psychological health (Kashdan & Rottenberg, 2010).

Psychological inflexibility
Psychological inflexibility is the opposite of psychological flexibility and is characteristic of low BIF. Inflexibility can manifest as the effort to avoid internal events, even when doing so leads to behaviours inconsistent with one's values and goals. Alternatively, it can involve internal events controlling behaviour to the extent that values and goals are compromised (Hayes et al., 2006). According to the ACT model, inflexibility is both a primary source of, and an exacerbating factor in, psychopathology (Hayes et al., 2006). There is strong empirical evidence pointing towards inflexibility as a major theme of many psychological disorders, including depression, anxiety, and eating disorders (Kashdan & Rottenberg, 2010; Sandoz et al., 2013).  Chloe tries on an outfit in a store and realises that she has gone up a size since last time she went shopping. She is upset and angry with herself that she didn't notice she was gaining weight.}

{What is Chloe most likely to do if she has low BIF?}


 * type=""}

+ Buy her previous size as motivation to lose weight, even though she wanted to wear the outfit now. - Tell herself: "I still look good; this outfit suits me better with more curves anyway" and buy the correct size. - Think "It’s OK that I'm upset, but I'm going to buy the right size because I want to be able to wear it".

{What might Chloe do if she has high BIF?}


 * type=""}

- Buy her previous size as motivation to lose weight, even though she wanted to wear the outfit now. - Tell herself: "I still look good; this outfit suits me better with more curves anyway" and buy the correct size. + Think "It's OK that I'm upset, but I'm going to buy the right size because I want to be able to wear it".

Relationship between body image flexibility and disordered eating


Body dissatisfaction, particularly among women, is so pervasive that it has been referred to as "normative discontent" (see Figure 1). For example, in a study of over 5,000 American women, 91% were dissatisfied with their current size (Runfola et al., 2013). Body dissatisfaction is a strong predictor of disordered eating and a diagnostic criterion for both anorexia nervosa and bulimia nervosa (Lee et al., 2017). Why, if body dissatisfaction is so widespread, are eating disorders relatively rare? The explanation for this may lie in BIF.

Body image flexibility and the development of eating disorders
BIF is theorised to serve a protective function against eating disorders, in that it prevents individuals from using maladaptive coping techniques in response to the body image threats that they will inevitably experience (Rogers et al., 2018). Maladaptive coping techniques include avoidance and appearance fixing, as well as disordered eating behaviours such as binge eating and purging (Cash et al., 2005; Moore et al., 2014). Empirical evidence supports this theory, with multiple studies finding that BIF serves as a moderator and partial mediator in the relationship between body dissatisfaction and eating disorder psychopathology (Rogers et al., 2018). Moreover, low BIF has been found to cause the relationship between body dissatisfaction and avoidance and appearance fixing responses (Mancuso, 2016). Additionally, for individuals who display disordered eating cognitions, high BIF prevents them from actually engaging in disordered eating (Moore et al., 2014; Wendall et al., 2012). Low BIF may be necessary to develop an eating disorder, even when body dissatisfaction and disordered eating cognitions are present.

Body image flexibility and the treatment of eating disorders
Predictably, BIF is consistently lower in individuals with eating disorders than in the general population (Rogers et al., 2018). Conversely, individuals with eating disorders display high levels of psychological inflexibility, which serves to promote and maintain psychopathology (Ferreira et al., 2011). Promoting adaptive cognitive and behavioural regulation of distress through BIF is, therefore, important to treatment. Additionally, eating disorder treatments traditionally focus narrowly on reducing negative body image, the best result of which is patients tolerating their bodies. Incorporating promotion of positive body image constructs, such as BIF, may help patients appreciate and respect their bodies, leading to better outcomes (Fogelkvist et al., 2020).

Studies assessing BIF in the context of eating disorder treatment provide support for the importance of targeting it. Early improvements in BIF during treatment predict greater reduction of symptoms and better eating disorder-related quality of life post-treatment, as well as better general mental health (Lee et al., 2018; Pellizzer et al., 2019). Additionally, Pellizzer et al. (2019) found that higher BIF was associated with lower eating disorder psychopathology at all points of treatment, and at a three-month follow-up. Further research is required to confirm that the role BIF plays in positive treatment outcomes is causal (Lee et al., 2018). However, there is clear preliminary support for including BIF promotion in the treatment of eating disorders.

What are the effects of high body image flexibility on well-being?


BIF, as an adaptive emotional and behavioural regulation strategy, is universally associated with positive psychological outcomes. The most obvious benefits of BIF are body image and eating related. BIF is also related to multiple aspects of general psychological well-being.

Body image
Across multiple studies, people with high BIF consistently report lower body dissatisfaction than those with low BIF (Rogers et al., 2018). This inverse relationship exists because avoiding or suppressing internal events causes the gradual increased intensity of these events. Therefore, individuals with high BIF may experience less body dissatisfaction because they do not engage in avoidance or suppression, meaning that they experience fewer distressing feelings, thoughts, sensations, and memories about their bodies (Rogers et al., 2018).

BIF is positively related to other facets of positive body image, such as body appreciation, which refers to accepting, respecting, and nurturing the body and its imperfections (Webb et al., 2015). Moreover, BIF may help individuals to cultivate body appreciation as a response to experiencing body image stressors (Webb, 2015). It is, therefore, important to overall positive body image.

Eating
Given the negative correlation between BIF and eating disorders, high BIF is predictably related to psychologically healthy eating habits. Firstly, Duarte, and Pinto-Gouveia (2015) found that BIF is significantly negatively associated with emotional eating. Emotional eating is a form of inflexibility, as it typically represents an attempt to avoid distressing emotions. Secondly, individuals with high BIF are less likely to engage in rigid dieting (Rogers et al, 2018; Tan et al., 2019; Timko et al., 2014). While flexible dieting can be positive, rigid dieting is associated with weight gain and is a risk factor for eating disorders (Duarte et al., 2017).

Intuitive eating, alternatively, is an adaptive style of eating that benefits health and well-being (Schoenefeld & Webb, 2013). It entails the ability to eat in response to physiological cues rather than external inflexible diet rules or internal emotional states (Cardoso et al., 2020). Therefore, like BIF, it involves acting in congruence with one's needs, regardless of barriers. High BIF has been linked to higher levels of intuitive eating by multiple studies (Cardoso et al., 2020; Rogers et al., 2018).

Psychological well-being
BIF is particularly strongly correlated with self-compassion and mindfulness (Rogers et al., 2018). Self-compassion and mindfulness are both important aspects of well-being that are interrelated with BIF, with all three constructs involving awareness and acceptance of internal events (see Figure 2) (Kelly et al., 2014). In eating disorder interventions, increases in BIF parallel increases in both mindfulness and self-compassion (Butryn et al., 2013; Duarte, Pinto-Gouveia, et al., 2017)

In ACT, psychological distress is conceptualised as the result of low levels of psychological flexibility (Rogers et al., 2018). It, therefore, makes sense that high BIF is associated with lower levels of aspects of psychological distress. For example, BIF negatively correlates with depression, anxiety, and stress (Ferreira et al., 2011). It also negatively correlates with self-concealment, which is a distress-promoting pattern of hiding personal information from others, and perfectionism, which is a distress-promoting inflexible trait (Masuda et al., 2018; Rogers et al., 2018). Furthermore, Schoenefeld and Webb (2013) found that BIF was associated with the ability to tolerate distress. Finally, individuals high in BIF are likely to also possess high general psychological flexibility, further benefiting their well-being (Sandoz et al., 2013).

How can body image flexibility be developed?


Research regarding the development of BIF is currently severely limited. The vast majority of BIF research is cross-sectional in nature, making it difficult to determine the cause of differing levels of BIF. Additionally, most interventions draw samples from eating disorder treatment, making generalisability to non-clinical populations limited (Rogers et al., 2018). To date, almost all BIF interventions have utilised ACT, with promising results (Rogers et al., 2018). Psychological flexibility is the central mechanism of therapeutic change in ACT, making the therapy theoretically well suited to target BIF.

Acceptance and commitment therapy
Recent treatments for eating disorders have begun to use third wave cognitive behavioural therapies, such as ACT, to improve acceptance of distressing body image-related internal events (Timko et al., 2014). ACT aims to increase psychological flexibility through six processes of change: value-driven behaviour, commitment to value-driven behaviour, cognitive diffusion, self-as-context, acceptance, and contact with the present moment (see Figure 3) (Hayes et al., 2006). Patients are taught to clarify their values, so that they can prioritise them over the behaviours to control their body image that may have taken over (Fogelkvist et al., 2020). Patients work on cognitive diffusion to decrease their belief that their perceptions are factual, which drives appearance fixing behaviour (Fogelkvist et al., 2020). Self-as-context refers to the patient realising that they are not defined by their negative thoughts and feelings about themselves (Hayes et al., 2006). Finally, developing contact with the present moment and acceptance helps patients to decrease their usage of maladaptive emotional regulation techniques such as restricting food (Fogelkvist et al., 2020). Each of these six processes is addressed using a combination of behaviour change methods and mindfulness and acceptance exercises (Hayes et al., 2006).

Evidence for the use of acceptance and commitment therapy
ACT has led to positive results in eating disorder treatment outcomes, including increased BIF. Studies involving patients with restrictive eating, binge eating disorder, purging disorder, and problematic emotional eating have found that ACT reduces symptomology while increasing BIF (Hill et al., 2020; Duarte, Pinto-Gouveia et al., 2017). Beyond eating disorder treatment, BIF improvements have also been reported in ACT interventions targeting body dissatisfaction, depression in obese women, and psychosomatic disorders (Givehki et al., 2018; Rogers et al., 2018).

To date, only one study has utilised an ACT protocol specifically targeted at improving body image. In this study, ACT for body image was significantly more successful than treatment as usual in reducing eating disorder symptomology and body image issues; however, BIF specifically was not measured (Fogelkvist et al., 2020). Future research should investigate whether ACT targeted at body image produces better BIF outcomes when compared to a more general approach. Additionally, while ACT is a promising method of improving BIF, the literature base remains small. Further research is required to determine ACT's applicability to improving BIF in different populations, such as individuals with body dysmorphic disorder and individuals at risk of eating disorders.



ACT can be delivered in many different ways, including group therapy, brief interventions, or as a long-term therapy. It is also becoming increasingly accessible as a self-help tool. This website lists a number of resources that you can use to build your psychological flexibility. To increase your BIF, the Record app may be particularly helpful. It uses evidence-based cognitive behavioural and acceptance-based strategies, and can be used by anyone who struggles with disordered eating or body image issues.

Conclusion
Despite its recent conceptualisation, BIF is already proving important to the field of body image research. Drawing from psychological flexibility and positive rational acceptance, BIF positions adaptive affect regulation as essential to maintaining a positive body image. It includes the ability to accept one's thoughts and feelings about one's body, and to commit to pursuing valued actions even when they are in opposition to these thoughts and feelings (Rogers et al., 2018). Low BIF is thought to be the mediating factor causing body dissatisfaction to lead to eating disorders (Lee et al., 2017), and is linked to body dissatisfaction, disordered eating, and psychological distress. Conversely, high BIF holds benefits for well-being including better body image, healthy eating habits, mindfulness, self-compassion, and psychological flexibility. Evidently, encouraging BIF is a worthwhile goal, particularly for people with negative body image and symptoms of disordered eating. ACT, which is aimed at increasing flexibility, is likely to be the most effective method of increasing BIF.

Body dissatisfaction is experienced to some degree by almost everyone, while mild disordered eating behaviours and cognitions are also very common (Runfola et al., 2013; Wendell et al., 2012). Therefore, it is important to acknowledge that BIF is not only relevant to people with eating disorders. BIF has numerous benefits that can improve anyone's well-being. In the future, as research progresses, therapy and self-help programs specifically designed for BIF will likely become available. In the meantime, ACT is an effective and accessible way to develop the flexibility that can improve one's responses to body image experiences.