Positive Body Image Workbook A Clinical and Self

Improvement Guide

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Positive Body Image Workbook
A Clinical and Self-Improvement Guide
Nichole Wood-Barcalow, PhD
Tracy Tylka, PhD
Casey Judge, PhD
University Printing House, Cambridge CB2 8BS, United Kingdom
One Liberty Plaza, 20th Floor, New York, NY 10006, USA
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pursuit of education, learning, and research at the highest international
levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/9781108731645
DOI: 10.1017/9781108758796
Cambridge University Press © 2021
This publication is in copyright. Subject to statutory exception and to the
provisions of relevant collective licensing agreements, no reproduction of
any part may take place without the written permission of Cambridge
University Press.
First published 2021
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in this publication and does not guarantee that any content on such
websites is, or will remain, accurate or appropriate.
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Every effort has been made in preparing this book to provide accurate and
up-to-date information that is in accord with accepted standards and
practice at the time of publication. Although case histories are drawn
from actual cases, every effort has been made to disguise the identities of
the individuals involved. Nevertheless, the authors, editors, and
publishers can make no warranties that the information contained herein
is totally free from error, not least because clinical standards are
constantly changing through research and regulation. The authors,
editors, and publishers therefore disclaim all liability for direct or
consequential damages resulting from the use of material contained in
this book. Readers are strongly advised to pay careful attention to
information provided by the manufacturer of any drugs or equipment
that they plan to use.
Contents
Foreword vii
Acknowledgments x

Section I Introduction and Preparation 13.

14.
Objectification and Self-Objectification 183
Sexual Intimacy 203
1. Introduction to the Positive Body Image Workbook 1 15. Social Comparison 219
2. Client and Reader Preparation 7 16. Body Talk 231
3. Clinician Preparation 32 17. Protective Filtering 249
18. Rippling Effect: Mentorship 267
Section II The Journey Toward Positive Body 19. Self-Care 280
20. Fueling Our Bodies 296
Image 21. Life-Enhancing Movement 319
4. Appearance Ideals and Media Literacy 43 22. Adaptive Appearance Investment and Quality of
5. Weight Stigma versus Weight Inclusivity 68 Life 342
6. Body Acceptance by Others 95
7. Defining Beauty and Cultural Pride 107 Section III Continuing Our Journeys
8. Self-Compassion and Body Image Flexibility 118
9. Approaching Our Bodies 133 23. Next Steps in the Journey 361
10. Body Appreciation 147
11. Functionality Appreciation 156
12. Embodiment 175
Index 365

Online resources
All assignments from the book are available to download
and print for use in sessions via: www.cambride.org/PBIW
Password: PBIWorkbook21
v
Foreword

For 33 years I taught abnormal psychology, introductory psy- middle school resumed in the fall (see the epigram at the
chology, and an upper level seminar on eating disorders at a beginning of chapter 22). And a mere 2 years later the Beatles
liberal arts college. Most of the students I taught were in the top and their “mop top,” ear-obscuring hair became an interna-
10% of their high school classes. Around 75% eventually went tional sensation, and a sexiness ideal for White boys in middle
on to graduate school and/or professional training in fields and high school, including those of us with curly hair . . . .
such as psychology, medicine, law, the arts, or business. Body image. Body dissatisfaction. Shame. Should. Ought. If
Typically, the students were very bright, curious, and analyti- only I looked like . . . . A few words, easily processed and
cal. We had lively, sometimes boisterous discussions, often with elaborated in cool, conceptual form (e.g., actual-ideal dispar-
personal examples, of a great many topics. These included lan- ity) while reading about and in some instances discussing these
guage, symbolism, and Freudian psychosexual stages; the plea- topics. But where to begin—as a person who wants to be
sures, hilarity, risks, and all too frequent tragedy of alcohol and healthier, as a grand/parent determined to resist imposing
other drug use; and people we have known—and, in some sad their past and the culture’s stifling present on children, as a
instances, grown up with—who had The Dark Triad of person- counselor or a coach or a physician who wants to be a positive
ality characteristics (Furnham, Richards, & Paulhus, 2013): nar- influence—to understand the hot emotionally and morally
cissism, subclinical psychopathy, and Machiavellianism. Only charged layers of body image? The whole matter is complicated
one topic, from fall 1980 through spring 2012, unfailingly evoked by the fact that the geography of body image reflects an unruly
uncomfortable silence. If your first thought is trauma, think and set of influences ranging from genetics, to teasing, to trauma,
feel again. to gender/sexual identity, to advertising as it represents eco-
Body image was and remains for most people simulta- nomic and political forces.
neously too personal, too interpersonal, and too complex. It It’s hardly sage advice for me to offer you Internet platitudes,
is freighted with strong emotions, it is deeply rooted in our past such as “Stop. Breathe deeply. Step up, be mindful, and begin
while always lurking in the immediate future, and it is influ- somewhere. Love yourself. Embrace health. Be the change you
enced by a network of powerful forces in our cultures. When wish to see in the world . . .” But “Read and use the Positive
“body image” became the focus of that social phenomenon we Body Image Workbook” is not only sage advice, it is a compas-
call a “college class,” one could almost see and smell the self- sionate, effective, and socially constructive move on my part.
consciousness and shame seep into the room, like foul-smel- In fact, this is a book not only to be read, it calls us to engage
ling smoke under a door. with it mindfully, frequently, and in an intentionally recursive
I offer this observation neither as an experienced college way. Whether you are a curious teenager, a frustrated 30-
professor nor as a body image expert. Standing or sitting something dieter, or a pediatrician, this book is a unique and
with my students in class I experienced it, too. Every time. rich means of beginning to learn and practice the very skills
And right now in memory, as the adult form of a small, necessary to improve our own body image, those of people we
physically frail boy growing up in 1950s and 1960s southern know and care about, and our societies in general. And, ulti-
California, with big ears, easily irritated skin, and curly hair mately, the Positive Body Image Workbook will likely enable
and long eyelashes that girls envied, right above eyes that you to “love yourself” and “be mindful” and “embrace health”
necessitated glasses at age 7 . . . a mere 2 years after I really and “be the change you wish to see in the world.”
began to need them. In the early 1960s, puberty and acne With its focus on skills and learning as they apply to each
underway, I and my misery/shame/helplessness prevailed person, this book is, in the words of Dr. T. Aaron Beck, founder
upon my thrifty middleclass parents to give money and time of Cognitive Therapy, person-centered and problem-focused
they could ill afford to securing for me what was then called (Beck, Rush, Shaw, & Emery, 1979). In this regard, I call your
“plastic surgery.” At a hospital 50 miles away in Los Angeles attention to the chapter that covers one important aspect of
the bones in my “hey, there’s Dumbo!” ears were rearranged in positive body image: body acceptance. Chapter 6 of Positive
order to set them back toward my head. This helped for a while, Body Image Workbook exemplifies how this book helps each
although I wonder how many of my peers noticed, really, when reader as an individual to understand, accept, and overcome
vii
 Foreword

without a wasteful, self-critical fight the neurotic dynamics of healthy, sustainable changes toward body positivity within a
negative body image, that is, the self-defeating and self-perpe- fuller life. This book literally enables you to practice engaging,
tuating vacillation between dysphoria (shame, anxiety, guilt), instead of avoiding, the dialectic between acceptance of the
avoidance, and rumination. The Positive Body Image unchangeable and commitment to applying skills for what can
Workbook directly, matter of factly, and compassionately be changed—and the proverbial wisdom to know the differ-
helps the reader to identify nonjudgmentally and then address ence. This encouragement is particularly important for
the many external and internal forces that threaten and some- approaching one’s body image, which may feel intractable.
times overwhelm body acceptance. This book itself, infused Tracy, Nichole, and Casey are authoritative—knowledgeable
with the wise voices of its authors, is a great foundation, in and nurturing—throughout this book. They also consistently
terms of modeling, advice, knowledge, and support, for begin- serve as models for the courage to change. They know the task
ning to build and participate in what the authors call a of transcending the past and the culture (not to mention the
Community of Acceptance (see chapter 17). self) is daunting. They know there will be experiences of con-
The methodology of the Positive Body Image Workbook is fusion, anxiety, and shame, and they know there will be set-
grounded in a flexible form of therapy, teaching, and strategic backs. And in every chapter they are willing to be there—and
encouragement that emerged nearly 100 years in the decidedly for us to join them in the enterprise—with their healthy values
non-Freudian eclecticism of Alfred Adler (1929). Adler’s and to stay present and mindful, and to take action, all in the
approach to therapy, education, and indeed social change presence of anxiety, doubt, and humility.
combined brief lectures, guided discussion, analogies, stories, I was initially a bit reluctant to agree to write a foreword
homework assignments, humor, and careful, multifaceted ana- about a “workbook,” even though I have known, admired, and
lysis of cognitions we accept as painful, suffocating truths drawn upon the work of Tracy and Nichole for over 15 years.
instead of the mis/guiding, malleable fictions they really are. After all, I am not a clinician, I was trained to be suspicious of
And yet the Positive Body Image Workbook couldn’t be more anything that was not a peer-reviewed journal article, and, yes,
rooted in and guided by current research and evidence-based I’ve spent too many painful hours either avoiding or ruminat-
practices to reducing negative body image while developing a ing about my own body image issues. And as an advocate for
positive body image. I counted explanations, guidance, and the prevention of negative body image and disordered eating, I
exercises, from, in alphabetical order: Acceptance and believe in the prospect and the psychosocial significance of
Commitment Therapy (ACT), Behavior Therapy, Cognitive positive body image, and I need to practice being courageous.
Therapy, Cognitive Behavior Therapy (CBT), Dialectical I found, to my delight, that in reading the Positive Body Image
Behavior Therapy (DBT), Feminist Therapies, Health at Workbook I had the privilege of learning much more about
Every Size® principles, Media Literacy, Mindfulness-Based negative body image (e.g., self-objectification; chapter 13) and
Therapy, Motivational Interviewing, and Stress Inoculation positive body image (e.g., protective filtering; chapter 17). I
Training. These are integrated by the book’s systematic yet also had the “life-enhancing” (see chapter 21)—personally,
flexible approach to helping people make significant changes professionally, politically—opportunity to discover in each of
and by the wisdom of the authors, drawing on their vast the 23 chapters four of the pillars holding up the foundation of
experiences in research, clinical work, and self-reflection. positive psychosocial development, of which positive body
Another truly unique aspect of the Positive Body Image image is so clearly a major dimension.
Workbook is its layered approach to self-assessment. This fea- The first pillar is compassion for the complexity, confusion,
ture derives from the authors’ expertise, and in some instances and challenges evoked by “working” in any manner, including
their leadership, in the science of tests and measurements for use of a workbook, on body image. The authors understand, at
assessing facets of body image. The authors guide the reader in all levels, that body image is not “just” anything. Rather, it is a
self-assessment—and thus a deeper understanding of impor- fascinating but bewildering network of beliefs, strong feelings,
tant constructs—by making extensive use of valid question- sensations, visual images, auditory echoes, and, to paraphrase
naires and opened-ended, semi-structured questions. At the Carl Jung (1965), “memories, dreams, and reflections.”
simpler levels this connects with the reader’s desire to under- Moreover, all these important dimensions are embedded in
stand multidimensional concepts more fully and how they transactions with how we behave and the contexts in which we
apply to the self. Here there is guidance for scoring question- live. Second, the authors, by virtue of their extensive years of
naires and interpreting total scores. However, two truly dis- research, clinical work, advocacy, and self-reflection, have the
tinctive features of the Positive Body Image Workbook skills to provide us with the specific skills we personally need to
constitute the more complex levels. One is inviting the reader (a) understand the positive and negative dimensions of body
to return to their responses to individual questionnaire items image, and then (b) gently and fiercely tackle the challenge of
to explore those responses, as well as the productive potential long-term change while embracing the process of discovering
inherent in alternative responses. This sets the stage for the what positive body image means to us in the context of our
transition to using such in depth self-assessment for goal- own body agency.
setting and for anticipation of both supports and obstacles. Third, along with compassion, the authors infuse this work-
Without either complicating or oversimplifying the task, the book with the determination, reinforcement, humor, and
Positive Body Image Workbook provides, in clear steps, the patience necessary to help people learn through doing that
perspective, the motivation, and the skills necessary for change is a practice. This is the rare workbook that is well-
viii
 Foreword

researched by world-class experts and well-organized by scien- memory, but well into pain that can be all too fresh. This book
tists who are clear thinkers and effective writers. And these has provided me with knowledge, inspiration, self-compassion,
authors know that to use this workbook effectively, one has to skills, and more, including the willingness to learn and practice
do what one does while engaged in any process of meaningful embodying its important lessons.
change—go back and forth, across the chapters, across the
exercises, across the years of one’s life, across the skills, across – Michael P. Levine, Ph.D., FAED
the dialectic between acceptance and change. This leads to the Goleta, California, 9 March 2020
final pillar, which is the importance of being guided by experts
who are part of a community in which they themselves con- Adler, A. (1929). The practice and theory of individual psychology
tinue to develop personally, professionally, and politically in (Rev. ed.). London: Kegan Paul, Trech, Trubner & Co.
terms of the power to transform a world that all too often Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive
makes positive body image sound preposterous. therapy of depression. NewYork: Guilford Press.
I am a psychologist who works in the body image and eating Furnham, A., Richards, S. C., & Paulhus, D. L. (2013). The Dark Triad
disorders fields. As noted, I am also an advocate for prevention of personality: A 10 year review. Social and Personality Psychology
of eating disorders and related conditions, including body Compass, 7, 199–216.
dissatisfaction. And I am a 70-year-old husband and father Jung, C. G. (1965). Memories, dreams, reflections (A. Jaffé, Ed.). New
whose body image issues stretch sideways and back beyond York: Vintage Books.

ix
 Acknowledgments

Thank you . . . invaluable feedback to contribute to the success of this

Cambridge University Press and the amazing editorial staff workbook.
for believing in us and joining with us in this exciting Cherished clients for your wisdom, courage, trust, and vul-
collaboration. nerability. May this workbook be in honor of your struggles
Esteemed colleagues for contributing to the field of positive and successes.
body image, encouraging us to engage in this endeavor, Dear families, friends, and mentors who walked with us each
allowing the use of your intellectual property, and offering step of the way with unwavering support and love.

x
 Section I Introduction and Preparation
Chapter
Introduction to the Positive Body Image Workbook

1
Welcome to the Positive Body Image Workbook! In this chapter, workbook) as well as our clinical experience of witnessing
we offer an overview of positive body image, introduce our- clients transform from negative to positive body image.
selves and our work, share what inspired us to write this work-
book, and describe how you may use it in your clinical practice Who We Are and Our Guiding Beliefs
(for clinicians1) and everyday lives (for clients and readers2).
We are three colleagues and friends who have collaborated on
published studies related to body image, intuitive eating, and
What is Positive Body Image? disordered eating, and have provided services (including psy-
This workbook focuses on increasing positive body image and chotherapy and trainings) focused on promoting positive body
reducing negative body image. Right now, you may be wonder- image. We share similar values (integrity, collaboration, and
ing, “Won’t reducing negative body image automatically quality research and clinical work) and a passion to help all
improve positive body image?” In some ways, yes – but not in those who want to move toward positive body image. We
all ways. Negative body image includes negative feelings and believe that positive body image is attainable for any and all
thoughts about our appearance. Positive body image is broader who are willing to commit and invest in it.
than simply “positive feelings and thoughts about our appear- We each have our Ph.D. in counseling psychology,
ance.” Positive body image includes appreciating our bodies in a discipline that focuses on individual strengths to help build
terms of how they function along with appearance. It means resilience when faced with challenges while also promoting
loving our bodies for their unique characteristics, which may meaningful and fulfilling lives [1]. We draw from positive psy-
change across time (e.g., “our scars are beautiful”). Holding chology, the scientific study of human strengths that help people
a positive body image means that we perceive a wide range of thrive and cultivate what is best within themselves [2].
appearances as beautiful, not just the bodies portrayed as attrac- Incorporating strength-based approaches into clinical treatment
tive in social media, magazines, TV, movies, etc. Positive body enhances outcomes beyond focusing solely on what is wrong [3].
image also includes how we “bounce back” from body image Counseling psychologists honor multiple social identities (e.g.,
threats (or attacks on body image), such as negative comments race, gender, class, age, weight, sexual orientation, gender iden-
made about our bodies. Positive body image can be expressed as tity, ability, etc.), explore how these social identities interact to
taking care of our bodies (e.g., self-care), showing the world that shape experiences, and work to dismantle discrimination and
we feel positively about and respect our bodies, and mentoring stigmatization.
others to hold a positive body image as well. And, as you will Our professional and personal identities shed light on the
see in this workbook, it is so much more. perspectives we bring to this workbook. We have had experi-
Some people believe that it is unrealistic to have a positive ences with both privilege and disadvantage throughout our
body image. This skepticism is related to a narrow definition of lives which shape our worldviews, and as a result, how we
positive body image: “loving every aspect of the body at all view body image work. We offer some of our guiding beliefs:
times” without experiencing discomfort or moments of negative • Positive body image is unique from negative body image.
body image. We agree that this outcome is unachievable when • Positive body image is attainable for all persons of varying
defined in this way, especially in cultures that value appearance social identities.
ideals. Furthermore, we acknowledge that we all have moments • It is important to focus on changing internal experiences of
in which our body image is not what we would like it to be. Our body image rather than external appearance. The problem
definition of positive body image, in contrast, includes loving with negative body image is not about the actual body itself
and accepting our bodies regardless of appearance and function- but rather viewing oneself as deficient or unacceptable. As
ing, showing compassion for differences and difficulties, and a result, we do not recommend weight loss goals for body
responding effectively when body image distress occurs. This image issues, given that weight and body mass index (BMI)
definition is based on research studies (which we provide in this

1
We refer to all professionals who work with clients who have body image concerns as “clinicians” to honor the diversity of professionals in this
area (e.g., psychologists, counselors, social workers, dietitians, nurses, psychiatrists, medical doctors, and more).
2
Those engaged in therapy are referred to as “clients.” The term “reader” is for anyone who is interested in using this workbook for self-
improvement.
1
 Introduction to the Positive Body Image Workbook

are rather poor indicators of health [4–5]. Instead, we We include assessments along with instructions and
promote self-acceptance and compassion. applications for your clients to use at different points of
• Biological issues and maladaptive behaviors (e.g., chronic treatment to gauge and demonstrate progress (e.g., clients
dieting, self-induced vomiting, excessive exercise) need to be can witness first-hand their objective change, substantiate
recognized and addressed in advance of body image work. gains to third party payors). We intentionally incorpo-
• Negative body image is, in part, a byproduct of societies that rated elements of various treatment modalities so that
idealize appearance and that treat individuals differently this workbook would be interesting and applicable to
based on weight and body size, with higher-weight clinicians with different theoretical orientations:
individuals often experiencing weight stigma. We advocate Cognitive Behavioral Therapy [6], Dialectical Behavior
to reduce weight stigma (as well as other types of stigma) at Therapy [7], Acceptance and Commitment Therapy [8],
various levels (e.g., societal, individual). Emotion-Focused Therapy [9], Compassion-Based
• A weight-inclusive philosophy (supporting the well-being Therapy [10], Interpersonal Therapy [11], Exposure
and health of people of all body sizes) is essential for moving Therapy [12], social justice [13], and Motivational
toward positive body image. Interviewing [14]. The assignments included in each
• Clinicians benefit from exploring how their own body image chapter can be reviewed during sessions and/or offered
issues impact themselves and the clients with whom they as homework assignments to assist your clients in moving
work. toward positive body image.
• Self-care (e.g., consistent nourishment, life-enhancing Of special note, we devote an entire chapter (Chapter
movement) is the essence of moving toward positive body 3 – “Clinician Preparation”) focused on how to help clients
image and requires intentional effort and practice. move toward positive body image within your clinical
work. We also offer specific considerations and assign-
ments for you as the clinician to promote introspection
Inspiration, Vision, and Integration into how your personal experiences intersect with that of
The inspiration for this workbook emerged many years ago your clients.
while Nichole contemplated how to share with fellow clinicians For the client and general reader: We offer factual infor-
and clients alike her process of synthesizing research concepts mation about positive body image that is based on research and
about body image into clinical practice. The vision was to clinical expertise. You can complete the assignments at your
create a workbook solely focused on practical applications to own pace based on your needs and interests.
promote positive body image that is grounded in research
findings along with clinical insights. Unique Features of Our Workbook
We recognize that communication challenges exist Our workbook offers these unique features in one source:
between researchers and clinicians who specialize in positive • Accessibility. An easy-to-use resource for clinicians, clients,
body image. We believe that researchers benefit from the and general readers who would like to know more about
clinical expertise of clinicians specializing in this area and positive body image and/or wish to improve their body
that clinicians benefit from integrating research findings into image.
clinical practice. As both researchers and clinicians ourselves, • Introspection. Preparation chapters for clients/readers
we have created this workbook with the goal of increasing (Chapter 2) and clinicians (Chapter 3) to increase self-
communication within the profession as well as making the awareness. Both of these chapters offer common
information available to the general public. For this particular questions and answers on how to move toward positive
workbook, Tracy drafted the “Theory and Research” sections, body image. For clients/readers, the chapter addresses
and Nichole and Casey drafted the clinical tools (“Talking topics such as motivation, values, strengths, purpose,
Points”, “Treatment Goals and Objectives”, “Applications”, goals, and more. For clinicians, the chapter focuses on
and “Assignments”). how to prepare both professionally and personally for
For the researcher: We integrate up-to-date research on this work. Assignments specially created for clinicians
positive body image topics from peer-reviewed journals are included.
and academic sources in the “Theory and Research” sec-
• Education. Nineteen chapters provide information on
tions. We reference each original source for additional
different components of positive body image such as
reading. We also offer valid and reliable assessments
embodiment, body appreciation, self-care, intuitive eating,
along with instructions on how to interpret them and
social comparison, body talk, and more.
apply them within a real-world context for each of the
• Intervention. Treatment planning tools, including “Talking
body image topics.
Points” along with treatment plan goals and objectives, are
For the clinician: We review relevant information
included in each chapter to promote effective clinical
about components of positive body image in an easy-to-
interventions.
read format that you can then share with your clients.
• Assessment. Twenty-one reliable and valid assessments with
The “Treatment Planning” sections offer specific talking
guidelines for interpretation and applications accompany
points that you can include in your sessions as well as
each body image topic.
goals/objectives that you can tailor for treatment plans.
2
 Unique Features of Our Workbook

Table 1.1 Workbook Overview

Section Portion Clinicians Clients Readers

I. Introductory Chapter 3: Clinician Preparation is Chapter 2: Client and Reader Preparation is
chapter specifically designed for the clinician specifically designed for the client engaged
(Chapter 1) and providing interventions for clients/ in body image work with a clinician or for
preparation group of clients with body image the interested reader who would like to
guides issues. This chapter offers suggestions learn about how to move toward positive
(Chapters 2–3) on how clinicians can: (a) help clients body image. This chapter includes
move toward a positive body image, information on problem identification, how
and (b) facilitate awareness of their to prepare for body image work, core values,
own body image experiences which character strengths, purpose, goals, and
can impact client interventions. committed action (and more!). Commonly
Commonly asked questions along with asked questions along with answers are
answers are included as well as included as well as specially created
specially created assignments to assignments to promote increased self-
promote increased self-awareness in awareness. It is recommended that the
the clinician. It is recommended that client/reader review this chapter before
the clinician review this chapter moving on to other chapters.
before proceeding with the rest of
the workbook.
II. The Journey Theory and Each content chapter includes an Each content chapter includes an overview of
Toward Positive Research overview of a particular body image a topic of body image based on information
Body Image topic complete with up-to-date from experts. Clients/readers can read the
(Chapters 4–22) information from researchers and information as well as share with important
clinical experts from around the world others (family, friends, and partners) to
in one source. A definition of the body increase understanding and sensitivity to
image topic is offered along with body image issues. Clients in therapy can
theory and research on the topic. share relevant topics with their clinician.
Clinicians can use these sections in
various ways: (a) read to increase own
knowledge, (b) offer as recommended
readings to interested colleagues, (c)
share highlights with clients during
interventions, and/or (d) encourage
clients to read on their own to discuss
during future interventions.
References are included at the end of
chapter for the clinician who is
interested in reading the original
citations.
Talking Talking points can be used to start Clients can circle Readers can journal
Points a conversation on specific body talking points to about relevant
image topics during interventions with address during talking points.
clients. treatment
interventions.
Goals and Sample goals and objectives that we Sample goals and The listed goals and
Objectives have used in the care of our own objectives are objectives provide
clients are offered for treatment plans. offered related guidelines for the
The goals and objectives reflect various to change. Goals body image
theoretical orientations. Clinicians can are desired journey. Goals are
work collaboratively with clients to outcomes that desired outcomes
select relevant goals and objectives are broadly that are broadly
based on individual needs and defined, while defined, while
preferences. objectives are objectives are
smaller smaller achievable
achievable steps steps towards

3
 Introduction to the Positive Body Image Workbook

Table 1.1 (cont.)

Section Portion Clinicians Clients Readers

towards goals. goals. Readers can
Clients can check relevant
check relevant goals and
goals and objectives to work
objectives to toward.
include in
treatment.
Additional Books, workbooks, websites, and more are offered as additional resources to deepen
Resources understanding of the body image topics in areas that extend beyond the scope of this
workbook.
Assessments Most chapters include at least one Most chapters include an assessment focused
assessment that corresponds with the on a topic of positive body image. Clients
theme of the body image topic that and readers can complete the assessments
has been authorized for use by the at various points throughout the positive
original cited author(s). Some of the body image journey. Guides for how to
assessments were slightly modified to interpret high, medium, and low scores are
be inclusive of gender fluidity, improve presented. Comparing the scores between
clarity, and increase relevance for timepoints is a useful way to determine
a range of client concerns. Interpretive progress.
scores are presented. Clinicians can use
assessments in various clinical pursuits:
(a) to determine client progress
(beginning, middle, end of treatment),
(b) to tailor treatment goals and
objectives unique to the client, (c) to
educate about different aspects and/or
nuances of a topic, (d) to open
dialogue about related topics, (e) to
increase client self-awareness that can
translate into change, (f) to sharpen
treatment focus, (g) to inform
homework assignments, and (h) to
demonstrate objective response to
treatment interventions. Integration of
these assessments can be beneficial for
those clinicians who are required to
demonstrate a client’s response to
treatment to an external entity (e.g.,
accrediting body, third party payor).
Clinicians can complete assessments
for their own personal growth. If
clinicians wish to use the assessments
for research purposes, they will need to
contact the original authors.
Assessment All assessments include corresponding All assessments include applications to guide
Applications applications to facilitate self-awareness and deepen reflection by way of thought-
via thought-provoking comments and provoking comments and questions.
questions. Clinicians can use the
applications: (a) to stimulate dialogue
during interventions, (b) to identify
future treatment interventions, and/or
(c) to encourage clients to complete as
take-home assignments. Clinicians can
complete assessment applications for
their own benefit.

4
 Applicability and Limitations

Table 1.1 (cont.)

Section Portion Clinicians Clients Readers

Assignments The purpose of the assignments is to The purpose of the assignments is to apply and
apply and extend information on the deepen information on body image.
body image topics. Different formats Different formats are offered: open ended-
are offered to be of interest to a wide questions, journal entries, thought
range of individuals: open ended- experiments, behavioral experiments, and
questions, journal entries, thought more. Clients/readers can choose which
experiments, behavioral experiments, ones to complete based on interest,
and more. Clinicians can integrate paying attention to themes that may
assignments in the following ways: (a) emerge. The assignments can be
serve as talking points during clinical completed multiple times to review
interventions for education purposes, change and progress. Also, clients/readers
(b) complete during clinical can share either the completed assignments
interventions, and/or (c) assign as or the themes from the assignments with
homework between interventions. important others (family, friends, partners).
Additionally, the same assignments Additionally, clients/readers can invite
can be completed at the beginning important and trusted others to also
and end of treatment to assess change complete the assignments with the goal to
and progress. Clinicians can complete share ideas after.
assignments for their own benefit.
III. Continuing Our Journeys This chapter serves as a wrap-up to the This chapter serves as a wrap-up to the
(Chapter 23) workbook. Intentional activities are workbook. Intentional activities are offered
offered along with encouragement to along with encouragement to develop
develop a plan to maintain them in a plan to maintain positive body image
daily life. Clinicians can reinforce the gains and prevent setbacks. Clients/readers
use of the activities with clients along can review this chapter when needing
with completion of the final a resource to get back on track toward
assignment that highlights journey positive body image.
reflections. Clinicians can review this
chapter for their own benefit.

• Application. An array of assignments is offered with the Applicability and Limitations

purpose of applying and extending information on the
We are honored for the opportunity to create this work-
body image topics. Readers can choose based on
book and intend for it to be applicable to a range of
interest.
people by:
• Sustainability. A final chapter is devoted to “intentional
activities” to ensure that the progress achieved is thereby • Including scholarly works from reputable resources around
maintained. the world.
• Ensuring that samples of people with various identities are
recognized and highlighted.
How to Use This Workbook • Using the term “they” throughout the workbook to
Because the chapters are independent of each other, you acknowledge that anyone can experience body image
can choose how to use this workbook: read it sequentially concerns regardless of gender identity.
from beginning to end, pick chapters to read that are of • Integrating currently acceptable language to describe groups
particular interest, and/or any combination. We encour- of people, acknowledging that this language is rooted within
age clinicians to own a copy of the workbook to: (a) share a Westernized lens and may not appeal to all.
general information about the different components of
We also understand that the field of positive body image is
positive body image with clients during sessions, (b)
relatively young, there is still much to be learned, and what is
make copies of chapters and assignments for clients to
understood as relevant today will likely morph over time. As
complete during the session or as homework, and (c) use
a result, we acknowledge the following limitations along with
for their own self-guided work on positive body image.
our efforts to address them.
We recommend that clients have their own copy of this
workbook to serve as a useful companion to therapy. • Some of the information in this workbook may be
In Table 1.1, we provide an overview of the various sections interpreted as complicated and dense. We have tried to
and components written from the perspective of the clinician, present the information so that it is accessible for the general
client in therapy, and general reader. reader.
5
 Introduction to the Positive Body Image Workbook

• We promote “body acceptance” throughout the workbook order to promote the client’s sense of personal choice,
while acknowledging that this experience may not be fully validation, and empowerment throughout this process.
relatable for all. For example, those who identify as
transgender may choose various forms of transition in order
to promote congruence with their gender expression(s) and Be the Change!
ultimately body acceptance. We encourage future research As mentioned in our guiding beliefs, we believe that change
endeavors to focus specifically on positive body image in is necessary at numerous levels to lower the incidence of
transgender and gender nonconforming individuals in order body image issues and to simultaneously promote positive
to fully appreciate and honor these experiences. body image. This workbook specifically targets change at the
• We mindfully refrained from integrating trauma-focused individual level by teaching skills to recognize and resist
content in the workbook. This decision was based on the harmful body-related messages while also promoting self-
collective philosophy that trauma-focused issues are most acceptance. Individuals can then create a rippling effect of
appropriately addressed within a therapeutic context, in change by inspiring loved ones, friends, community mem-
which the client’s unique needs and experiences are bers, and others to move toward positive body image.
honored. Trauma-focused therapy necessitates assessment Ultimately this change can permeate at a societal level. For
by a trained clinician to determine the appropriate stage example, individuals who apply the skills from this work-
of trauma work and to offer a recommended treatment book can get others involved by discussing the harms of
modality based on the client’s unique trauma history and weight stigma and the benefits of body acceptance, mentor
treatment goals. It is important to note that those with others to have a positive body image, boycott companies
histories of trauma may experience additional concerns that perpetuate weight stigma, and engage in social action in
related to their bodies such as self-protection, intimacy, many other ways.
body awareness, body trust, and body control. We We envision a collective effort of challenging appearance
encourage clinicians and clients to tailor the treatment ideals and combating weight stigma; a movement toward
tools, assessments, applications, and assignments within what really matters. We, the authors, commit to promoting
this workbook as clinically indicated to best fit the body acceptance within society, and we hope to inspire you
experiences of the client. Additionally, we recommend (clinicians, clients, and readers) to join us in this mission.
discretion when selecting workbook interventions in We are excited that you are taking this step with us!

overweight and obesity using standard 10. P. Gilbert. Compassion Focused

References body mass index categories: A systematic Therapy: Distinctive Features. London:
1. C. J. Gelso, E. N. Williams, and review and meta-analysis. JAMA 2013; Routledge, 2010.
B. R. Fretz. Counseling Psychology (3rd 309: 71–82.
ed.). Washington: American 11. M. M. Weissman, J. C. Markowitz,
Psychological Association, 2014. 6. J. S. Beck. Cognitive Behavior Therapy: and G. L. Klerman. The Guide to
Basics and Beyond (2nd ed.). New York: Interpersonal Psychotherapy:
2. S. J. Lopez, J. T. Pedrotti, and Guilford Press, 2011. Updated and Expanded Edition.
C. R. Snyder. Positive Psychology: The New York: Oxford University Press,
Scientific and Practical Exploration of 7. M. M. Linehan. DBT Skills Training
Manual (2nd ed.). New York: Guilford 2018.
Human Strengths (4th ed.). Thousand
Oaks: Sage, 2019. Press, 2015. 12. J. S. Abramowitz, B. J. Deacon, and
8. S. C. Hayes, K. D. Strosahl, and S. P. H. Whiteside. Exposure Therapy
3. M. E. P. Seligman, T. Rashid, and for Anxiety: Principles and Practice (2nd
A. C. Parks. Positive psychotherapy. Am K. G. Wilson. Acceptance and
Commitment Therapy: The Process ed.). New York: Guilford Press, 2019.
Psychol 2006; 61: 774–88.
and Practice of Mindful Change 13. E. Aldarando (Ed.). Advancing
4. Y. Brooks, D. R. Black, D. C. Coster, (2nd ed.). New York: Guilford Press, Social Justice Through Clinical
et al. Body mass index and percentage 2012. Practice. New York: Routledge,
of body fat as health indicators for 2007.
young adults. Am J Health Behav 9. L. S. Greenberg. Emotion-Focused
2007; 31: 687–700. Therapy: Coaching Clients to Work 14. W. R. Miller and S. Rollnick.
Through Their Feelings. Washington: Motivational Interviewing: Helping
5. K. M. Flegal, B. K. Kit, H. Orpana, et al. American Psychological Association, People Change (3rd ed.). New York:
Association of all-cause mortality with 2015. Guilford Press, 2013.

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 Chapter
Client and Reader Preparation

2
Welcome! practice. Additionally, it involves approaching uncomfortable
So you’ve decided that you want to address your body image emotions and thoughts along with behavioral changes.
issues with the goal of moving toward positive body image – Remember that you have a choice; you can choose to do noth-
good for you! It’s likely that you have had some concerns for ing, keep doing things in the same way, or do things differently.
a while and are now trying to figure out how to make positive Simply wishing or thinking about things will not result in
changes. Maybe you’ve tried different strategies to improve body change. There are pros and cons associated with working on
acceptance; some worked, some didn’t. Whatever your journey these issues versus not working on them at different points in
has been to date, we welcome you to our approach on how to your life. Complete Assignment 2.1 “Pros/Cons of Working on
embrace positive body image. Body Image Issues” to identify costs and benefits of changing
Some quick information about how this workbook is
versus keeping things the same.
structured.1 Each content chapter (Chapters 4–22) includes the
Even after you have decided that you want to make changes,
following sections:
it can be challenging because motivation naturally waxes and
• “Theory and Research” – information from experts about wanes. Some days you might feel inspired and other days you
a body image topic;
might wonder whether the work is worth it. It’s normal to feel
• “Treatment Planning” (“Talking Points”, “Goals”, stuck and overwhelmed. During those times, it can be helpful to
“Objectives”) – suggestions on topics to discuss with others;
refer back to your original reason(s) for wanting to make
sample goals and objectives for your journey;
change. Complete Assignment 2.2 “Preparing for Positive
• “Additional Resources” – recommendations for additional
Body Image Work” which focuses on the reason(s) why you
information;
want to make change, desired outcomes, what coping skills you
• “Assessments” with “Applications” – assessments related to body
can use during this process, and sources of support.
image that you can complete along with questions for
reflection; Upon responding to these questions, if you notice that your
ultimate focus is to change your body (e.g., lose weight, cos-
• “Assignments” – different types of activities to apply and
deepen information on body image. You can choose which metic surgery), then this workbook might not best fit your
ones to complete and which ones to share with important goals. If you notice that your ultimate focus is to change your
others (e.g., family, friends, partners). mindset about your body, then this workbook will help you on
your journey.
In this chapter, we offer frequently asked questions and What has impacted my current body image? Before any
answers about positive body image. We encourage you to read
change toward positive body image can take place, it’s
this chapter and complete the corresponding assignments before
moving on to the following chapters. These assignments will important to determine what your body image is currently
serve as a foundation for your work toward positive body like and the life experiences that have shaped it. Many
image and remind you of your reasons for this work. factors influence body image over time, such as comments
So let’s get started! Remember to be persistent, patient, and from family members, exposure to messages in media, body-
compassionate with yourself during this process. related changes with age, and more. These experiences can
be interpreted as negative, neutral, or positive and corre-
Warmly,
spond with different emotions, thoughts, stories, and beha-
Nichole, Tracy, and Casey
viors. Assignment 2.3 “Body Image across Lifespan” offers
suggestions on how to create a visual representation of your
What is the problem with my body image? It is helpful to identify
unique body image experiences over time and how they
the specific problem(s) related to your body image. Take
impact your current functioning. As you review these
a moment to clearly define the current problem(s) in one sentence:
experiences, you’ll notice:
__________________________________________________
__________________________________________________ • the emotions that can range from sadness, shame, anger, and
embarrassment to pride, satisfaction, and joy;
What can I do to prepare myself for body image work? Body • the thoughts and stories you believe(d) about yourself then
image work requires time and effort along with consistent and now related to these experiences;

1
A detailed description of the workbook can be found in Table 1.1: “Workbook Overview” in Chapter 1.
7
 Client and Reader Preparation

• the behaviors from trying to change your body, avoiding weight bias (judging ourselves or others negatively based on
uncomfortable experiences, altering your appearance, trying weight) is part of these reasons. Research shows that weight
new activities, and promoting positive change in others; stigma actually reinforces negative body image [4]. It is helpful
• how body investment (how much time or focus you spend on to shift the focus from weight loss to challenging internalized
your body) and body evaluation (how you judge your body) weight bias. Chapter 5 explains weight stigma and internalized
change at different points; weight bias in depth.
• how specific feedback and comments from others such as Moving toward positive body image is about internal
family members, friends, partners, medical professionals, acceptance versus changing external appearance. Our
coaches, teachers, mentors, community leaders, approach focuses on treating the mind and body with respect,
acquaintances, and even strangers impact your experience such as getting consistent nourishment, engaging in life-
with your body. enhancing movement, and fostering self-acceptance. The
body will respond in whatever ways it needs to.
What is important to me? As part of this journey, it is What will it take to change my body image from negative
important to consider your core values which serve as guide- to positive? Simply wishing or hoping for things to change will
posts in life. Values offer a point of focus and direction for likely not result in that outcome. Committed action, or the
moving out of a stuck place [1]. Examples of core values process of making small steps toward change [5], is necessary.
include justice, equality, freedom, love, compassion, service, Keeping your values, character strengths, and purpose in mind
intellect, success, respect, appreciation of beauty, humor, artis- is part of committed action. Each small step should be in the
tic expression, achievement, and financial security. Core values direction of your values. When engaging in committed action
can change throughout life depending on circumstances and remember to choose behaviors that aren’t too easy and not too
experiences. Complete Assignment 2.4 “Core Values” to iden- challenging; choose those that are just right. Take small steps
tify your top five core values and examine the degree to which that are challenging but not impossible, in order to build
behaviors in your life are currently aligned with your core a sense of accomplishment and to motivate for additional
values. action. Complete Assignment 2.8 “Committed Action toward
As unique individuals, we all have different combinations Positive Body Image”.
of character strengths [2]. Examples of these character It is helpful to recognize how engaging in certain behaviors
strengths include bravery, teamwork, forgiveness, curiosity, prevents you from moving toward positive body image.
zest, and perseverance. Check out the VIA Institute on Examples of such behaviors include excessive body checking
Character to learn more about character strengths and to or weighing, dieting, purging (e.g., self-induced vomiting, use
complete a free online scientific survey to determine your of laxatives or diet pills to control weight), excessive exercise,
top strengths. Consider how your “Character Strengths” self-injurious behaviors, consistent substance use, and more.
(Assignment 2.5) relate to your body image. Complete Assignment 2.9 “Behaviors that Move Me Toward or
Values and character strengths correspond with our sense Away from Positive Body Image”. This assignment can help
of purpose. Purpose is our reason for moving forward when you identify what behaviors move you further from or closer to
times are difficult. It is what energizes and inspires us to create positive body image (e.g., eating when hungry, stopping when
change for ourselves and sometimes others. Reflect on your full, being around others who accept your body, engaging in
unique “Purpose in Life” in Assignment 2.6 with special con- life-enhancing movement), and make specific goals to increase
sideration of how it relates to moving toward positive body these behaviors.
image. Additionally, respecting and protecting your body from
What are my body image goals? It is important to identify potential threats and harm corresponds with moving toward
goals related to positive body image as they lead us in a desired positive body image [6]. Examples of these protective behav-
direction towards our values. Goals can range from short-term iors can be asserting your needs, using sunblock, taking med-
to long-term. Try to be specific about what you want versus ications as needed, and getting vaccines. Review “Protection of
what you don’t want. Imagine having achieved your goal(s), the Body” (Assignment 2.10) to identify ways that you are
including associated emotions, thoughts, and behaviors. currently caring for your body and to learn additional ideas
Complete Assignment 2.7 “Body Image Goals”. of how to do so.
What if my goal is to change my body including lose Your mental perspective also impacts the transition from
weight? Research shows that weight loss is not effective long- negative to positive body image. If you notice that your
term; most people gain back the weight they lost and more [3]. thoughts are negative or pessimistic, try to be open to new
Examine your various intentions or reasons for wanting to lose ways of viewing yourself and your body without judgment.
weight. Examples might include not liking your current shape/ Practice replacing negative thoughts with positive thoughts.
size/weight, wanting to fit into certain types/size of clothing, Complete Assignments 2.11 “Practicing Body Acceptance” and
being instructed by your medical provider to do so for health 2.12 “Self-Affirmations”.
reasons, receiving negative appearance-based feedback from What challenges might get in the way of moving toward
a partner, or believing that weight loss will increase your positive body image? It is helpful to identify and anticipate
positive body image or overall quality of life. Upon identifying barriers associated with change so that you can problem solve
the reasons, it is helpful to consider whether internalized in advance. Complete Assignment 2.13 “Barriers and
8