Oncology interventions by necessity focus upon our patient’s body – the body is investigated, treated in a number of ways, and, monitored by various staff. All of this is essential, but it is also useful to have an understanding of body image psychology. For example, what do we mean by the term “body image”? How do bodily interventions and changes affect the individual’s psychological state? Why does this happen? What factors may be influential?
Exploring research within health psychology and theories of the body image can help to further understand patient experiences. In addition, such knowledge also provides a context in which to engage patients in conversation about their body, assist in history taking, monitor adjustment to intervention, and, recognise when referral to other services is required.
Relevance of body image in health care
Although any health related intervention will invariably involve the body in one way or another, research on the topic of body image has grown significantly during the past 20 years (Annunziata, Giovannini, & Muzzatti, 2012). Earlier research on body image focussed primarily on eating disorders, weight reduction and body shape issues, however, now there is increased emphasis being placed upon the role of body image upon the individual’s quality of life (Annunziata, et al., 2012; Falk Dahl, Reinersten, Nesvold, Fossa, & Dahl, 2010; Hopwood, Fletcher, Lee, & Ghazal, 2001).
Complexity in defining body image
It is recognised that defining body image is complex, multi-factorial and highly subjective, with further difficulties caused by a confusing plurality of terms (Thompson, 2004). More than 15 different terms are used to describe body image in research including “weight satisfaction”, “size perception”, “body satisfaction”, “appearance satisfaction”, “appearance evaluation”, “appearance orientation”, “body esteem”, “body concern”, “body dysphoria”, “body dysmorphia”, “body schema”, “body perception”, “body distortion”, “body image disturbance”, and “body image disorder” (Thompson & Heinberg, 1999; Annunziata et al., 2012). Thomas Cash, a recognised expert in the field, defines body image as the multifaceted psychological experience of embodiment, which encompasses body-related self-perceptions and self-attitudes, including thoughts, beliefs, feelings and behaviours (Cash, 2004).
Theoretical understanding of body image disturbance
A number of theories exist to explain how body image disturbance may arise. Higgins’ Self-Discrepancy Theory states that consequences develop when individuals compare their perceived self-image to their ideal image, and find that a discrepancy exists between the two (Higgins, 1987). Body dissatisfaction due to discrepancies between one’s perceived, actual, and ideal images, have been found to be associated with behaviours that attempt to reduce discrepancies, such as altered eating, increased exercise or undertaking cosmetic procedures (Vartanian, 2012). According to Baumeister’s Escape Theory, when individuals are confronted with recognition of a discrepancy between one’s actual and ideal self, they are motivated to escape that self-awareness (Vartanian, 2012). This can be attempted in a number of ways, such as substance use, self-harm, binge eating or other forms of emotional avoidance.
Body image dissatisfaction is further explained by Thomas Cash’s body image theories which discuss two subcomponents of body image – appearance evaluation and appearance investment. Appearance evaluation refers to the level of satisfaction with one’s appearance. In contrast, appearance investment refers to the importance placed upon appearance and physical attributes by the individual (Cash, 2011). With dysfunctionally high levels of investment, appearance is seen as central to an individual’s self-worth, (Cash, Melnyk, & Hrabosky, 2004). These two components of body image are essentially uncorrelated, and it is important to distinguish satisfaction with appearance from investment in appearance (Thompson, 2004). Using this perspective, it is recommended that both appearance evaluation and appearance investment be assessed in the individual (Cash, 2011). In other words, it is important for the health professional not only to ask whether someone is satisfied with their appearance, but also to enquire how much importance they place upon their physical appearance. Individuals who place a dysfunctionally high importance on their appearance as to part of their personal worth, are likely to be more at risk if they experience adverse bodily alterations.
Understanding positive body image
In oncology there is a growing interest in positive psychological functioning (Casellas-Grau, Vives, Font, & Ochoa, 2016). Positive body image is described as having love, respect, and acceptance for one’s body, with such individuals treating their bodies with care and appreciation for its function (Tylka, 2011). Research exploring body appreciation shows that it is a concept which goes beyond the mere absence of body dissatisfaction (Wood-Barcalow & Tylka, 2010). Body appreciation involves an understanding of what the body is able to do, its functionality, what it represents, its unique features, together with a broad conceptualisation of beauty with less emphasis on physical appearance as central to one’s self-worth (Tiggemann & McCourt, 2013; Tylka & Wood-Barcalow, 2015; Wood-Barcalow & Tylka, 2010). Individuals who are higher in body appreciation and positive body image are able to feel confident with their bodies and are more able to resist unrealistic, unhelpful social ideals by filtering information in a body protective manner (Tylka, 2011; Tylka & Wood-Barcalow, 2015).
Addressing health behaviours requires understanding the impacts of both positive and negative body image
Preliminary evidence suggests that positive body image is likely to be protective of physical health and psychological wellbeing, thus increasing one’s resilience, (Tylka & Wood-Barcalow, 2015). At the same time, negative aspects of body image cannot be ignored in the field of health promoting behaviours. For example, there are indications that body image concern may be a frequent barrier to breast and other cancer screening for women (Clark, et al., 2009), and therefore, negative body image needs to be addressed together with enhancement of positive body image. There are suggestions that both “upward spirals” of positive body image fostering growth, and “downward spirals” perpetuating negative body image distress could exist (Tylka & Wood-Barcalow, 2015), and both of these dynamics need to be considered by the health professional.
Impact of illness upon body image
During illness or injury, additional factors come into effect with regard to body image, and resultant impacts frequently go beyond the purely physical realm. Heightened awareness of the body has been reported as an outcome of physical illness (Fatone, Moadel, Foley, Fleming, & Jandorf, 2007). Some illnesses, injuries or treatment side-effects are sudden in their onset, and the abrupt nature of changes may present additional difficulties. It has been suggested that gradual changes of a disease process may allow for a gradual adaptation to changes in body image, and may be less psychologically traumatic than a sudden insult to the body (Samonds & Cammermeyer, 1989). During and after the experience of illness and/or treatment, an individual’s altered physical body can induce conflicted outlooks (Hefferon et al., 2010), with the body being both an indicator of human vulnerability and mortality, as well as a reminder of being alive and having hope in future (Goldenberg, Kosloff, & Greenberg, 2006; Hefferon et al., 2010). Therefore, those who receive medical treatment – especially multiple medical interventions – and undergo sudden bodily alteration may need specific psychological assistance with adjustment to physical changes.
Theoretical understanding of body image in oncology
In cancer patients, disease and treatment-related changes differ in their degree of observability, permanence, controllability and extensiveness (White, 2000) thus adding further issues for consideration. Moreover, the term ‘body image’ in cancer has not captured the complexity of the issues involved, and as such, researchers have generally failed to integrate findings from mainstream psychology to psychosocial oncology research and practice (White, 2000). Body image dimensions are largely inseparable from one’s feelings, and also need to take into account one’s personal investment (or importance) placed upon appearance attributes, and all these concepts need to be taken into consideration in oncology research and practice (White, 2000). White’s model illustrates the close relationship between cognitions, emotions and compensatory behaviours as final outcomes in relation to body image difficulties which are often the point of intervention for an oncology clinician.
White’s model can be understood further using a common example of cancer-related weight gain. A woman may experience an increase in her weight due to cancer treatments, and this change in appearance can activate her schemas (patterns of thoughts), for example “Attractive women must be slim”. The woman’s schemas can influence her level of investment in appearance as described by Cash (Cash, 2011), and the extent of ideal-actual body image discrepancy experienced as described by Higgins (Higgins, 1987). An example might be “It is important for me to be slim to be attractive and liked”, and “My body is very different to how it should look”. These aspects, in turn, are likely to influence situation specific negative assumptions, for example, “People are staring at me because I’ve gained so much weight”. These assumptions are then likely to influence the woman’s body image cognitions such as “I am ugly”, body image related emotions, such as fear and sadness, and compensatory behaviours, such as avoidance (e.g. not attending social events). As mentioned earlier, appearance investment appears to be a critical factor in cancer survivors due to the level of attention and importance the individual may direct towards any body image changes.
Assisting the cancer patient with body image resilience
Given the challenges of illness and adverse bodily changes for an individual with cancer, it has been suggested that enhancement of personal resources may assist with adaptation and adjustment to body image changes. Potential interventions may be focussed on physical aspects of the cancer survivorship experience, such as health and exercise programs, social resources including support groups, and psychological resources such as resilience or cognitive therapy programs (Phillips & Ferguson, 2013). There is evidence that self-compassion may be a particularly important additional personal psychological resource to develop in both younger and older age groups, due to its associations with psychological health (Barnard & Curry, 2011; Neff, 2011; Phillips & Ferguson, 2013). Self-compassion is the ability to show self-directed kindness in times of difficulty (Neff, 2003). Potential applications of self-compassion could be directed at an individual’s cognitions, emotions, and behaviours, consistent with White’s model (2000). With general populations, self-compassion has been associated with body image improvement, hence demonstrating specificity to body image difficulties (Albertson, Neff, & Dill-Shackleford, 2014). Self-compassion has also shown promise regarding assisting one’s openness to health promoting behaviours (Terry & Leary, 2011; Terry, Leary, Mehta, & Henderson, 2013), improvement of motivation (Breines & Chen, 2012), reducing experiential avoidance (Costa & Pinto-Gouveia, 2013), increasing acceptance of personal responsibility for mistakes (Leary, Tate, Adams, Allen, & Hancock, 2007), and promoting personal improvement after difficult experiences (Zhang & Chen, 2016). Self-compassion based writing interventions are now being researched as an intervention to assist women to cope with bodily alteration after breast cancer (https://www.breastcancer.org/research-news/writing-program-can-help-ease-body-concerns).
With increasing rates of survivorship of body image compromising medical conditions such as breast cancer, the demand for effective intervention is likely to become even greater with time.
The take home message
- Body image is a highly personal and subjective matter for the cancer survivor – be sensitive
- Satisfaction with appearance and personal importance attached to appearance (appearance investment) are important to assess
- Individuals with dysfunctionally high appearance investment may be more at risk for development of body image disturbance
- Ask about thoughts, feelings, and any compensatory behaviours related to adverse bodily changes
- Resilience in the face of adverse bodily changes can be enhanced by psychological therapies and survivor support groups. Self-compassion is showing promise in helping to build resilience to cope with adverse bodily changes
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