Body Image Flexibility

Tuesday, Dec 05  •  


By Alexandra Reveles
Doctoral Clinical Assistant

(Body A-C-C-E-P-T-A-N-C-E is possible)

In my previous blog post I shared with you a little bit about the body image work that we do here at Avalon Hills. I’m excited to share some research evidence with you that demonstrates the importance of body image flexibility, especially in regards to long term recovery outcomes. Avalon Hills is fortunate to collaborate with Dr. Michael Twohig (an expert in the Acceptance and Commitment Therapy field) and his research lab, in the Department of Psychology at Utah State University. The goal of this partnership is to improve understanding of our clients through assessment and determine our treatment effectiveness. This information is critical as we thrive on continued growth and improvement in our interventions. It is at the heart of our mission to stay on the front lines of eating disorder treatment.


Recently at our family week, we had the privilege of hearing about a joint Avalon-Twohig study from Eric Lee, M.A. who is a senior graduate student working with Mike. The study examined the Body Image-Acceptance and Action Questionnaire (BI-AAQ), which is part of our intake assessment battery that measures the extent that thoughts about body image are getting in the way of a person living a life that is meaningful to them. Some examples of BI-AAQ items are “I shut down when I feel bad about my body shape or weight” and “Worrying about my body takes up too much of my time” (Sandoz, Wilson, Merwin, & Kellum, 2013). Eric described psychological flexibility as “the ability to pursue meaning and value in your life to do things that you want while at the same time holding onto thoughts, judgments, sensations in the body that are [uncomfortable or difficult] so we can learn how to have those [difficult experiences] and do the things we want;”. Body image flexibility specifically refers to handling difficult experiences related to body image thoughts, sensations, and urges.

The research team found that changes in psychological flexibility in treatment are good predictors for positive treatment outcomes, but that body image flexibility was an even better predictor for positive change in treatment outcomes (Lee, Ong, Twohig, Lensegrav-Benson, Quakenbush-Roberts, 2017). More specifically, the increase in body image flexibility was linked to a higher quality of life, better mental well-being, and a lower eating disorder risk (Lee et al., 2017). This study supports a focus on body image flexibility during treatment because improvement in that area helps with improvements in others.

I’m sure you’re thinking, okay great!Treatment should have a focus on body image flexibility, but what does that really look like?

Well, it looks a lot like the things I talked about in my last blog post that we already do at Avalon such as, process groups specifically devoted to body image work and even body image individual sessions. Body image work is as individualized as each of our patients, everyone’s path looks different. It’s even a part of the weekend activities including exposure work such as swimming where patients are confronted with the need to wear a swimming suit in public while potentially (inevitably) dealing with some difficult emotions and thoughts. I focus on body image flexibility in therapy by engaging the clients with mirror exposures as a way for them to practice being with themselves and practice sitting with uncomfortable thoughts and emotions so they’ll be able to sit with them and still live their lives once they leave treatment. Sharon Walls, one of our primary therapists, and I often utilize mirror exposures in the body image process group as well. For the next body image group at the adult house we will really be practicing flexibility because I’ll be asking everyone in the group to pick a body part they struggle with and write a positive or neutral word on it to describe it. This is an attempt to reframe our thinking (aka cognitive diffusion) from our usual way of describing our bodies and see our bodies in a different light.

Eric gave a really nice acronym to describe how he thinks of practicing flexibility and that is to be BOLD:

  • Breathing deeply (and slowing down)
  • Observing
  • Listening to your values
  • Deciding on actions (and doing them)

He said this is something he tries to do in his own life and it is something I also try to practice when I’m feeling distressed. Remember, this is not a strategy you will master overnight, so the key is to keep practicing it. Eric put it simply when he said, “If you can learn to make space for the stuff you have (rather than avoiding it), identify your values and move toward those values, it will affect your treatment and you will improve.”


The benefits to positive outcomes that have been demonstrated by body image flexibility fall in line with Avalon’s treat to outcome philosophy, because of the core changes that are influenced by an increase in body image flexibility, and will continue to stay in the forefront of our treatment planning and focus. I encourage you to practice body image flexibility the next time you’re tempted to change your outfit before leaving the house or you have a disparaging thought or judgment about your reflection in the mirror. Those are two simple things that may lead to big boosts in living the life you want to live. The take home message really is that body image flexibility is attainable and leads to improvements in long term recovery outcomes.


Lee, E.B., Ong, C.W., Twohig, M.P., Lensegrav-Benson, T., & Quakenbush-Roberts, B. (2017). Increasing body image flexibility in a residential eating disorder facility: Correlates with symptom improvement. Eating Disorders: The Journal of Treatment & Prevention, 1-15, doi: 10.1080/10640266.2017.1366229

Sandoz, E.K., Wilson, K.G., Merwin, R.M., & Kellum, K.K. (2013). Assessment of body image flexibility: The body image-acceptance and action questionnaire. Journal of Contextual Behavioral Science, 2, 39-48.

Tags: Change