2019-CSWR_NewOrder.indd COLUMBIA SOCIAL WORK REVIEW, VOL. X | 1 DANCE FOR LIFE: USING A RESILIENCE MODEL TO FOSTER POSITIVE BODY IMAGE AND PREVENT BODY IMAGE DISSATISFACTION CORA B. RICHTER AND KIMONE C. COLEY INTRODUCTION A substantial majority of women—some 69–84% in the United States— experience body image dissatisfaction (Runfola et al., 2013), often beginning from a young age. Body image dissatisfaction is an empirically supported predictor of maladaptive eating behaviors such as dieting, bulimic behaviors, and weight gain (Bucchianeri, Arikan, Hannan, Eisenberg, & Neumark- Sztainer, 2013). It is also a risk factor for depression (Paxton, Neumark- Sztainer, Hannan, & Eisenberg, 2006) and a mediator of the relationship between body mass index and self-esteem (Bucchianeri et al., 2013). Accordingly, there is an urgent need for preventative interventions and programs where girls can develop the resilience to maintain healthy body image. Body image dissatisfaction is reported at higher rates among females in middle adolescence than among other groups (Lawler & Nixon, 2011; Bearman, Presnell, Martinez, & Stice, 2006), and is argued to be the core component of self-esteem in this population (Levine & Smolak, 2002). Research points to the range of 11–14 years as being a critical age for intervention to promote body image resilience and prevent body image dissatisfaction. Gardner, Stark, Friedman, and Jackson (2000) found that body dissatisfaction1 and larger perceived body size predicted elevated eating disorder scores at age 11 and thinner ideal body sizes at age 12. Meanwhile, Rohde, Stice, and Marti (2015) found that body dissatisfaction, among other factors, was significantly predictive of eating disorders within four years at age 14. Moreover, body image concerns affect millions more women and girls than eating disorders do (Choate, 2005)—making body image dissatisfaction a public health concern unto itself and providing an opportunity for researchers and clinicians to positively impact the lives of a substantial swath of the American populace (Choate, 2005). In light of this research and the reality of continuing familial, peer, and media-related pressures toward thinness, this paper addresses the need for programs and practices that bolster body image resilience in middle-school-aged girls. This paper has four goals. First, it will review the evidence explaining the sociocultural rise of body image dissatisfaction in adolescent girls. Second, it will depict current evidence-based interventions that address body image dissatisfaction and aim to prevent eating disorders and other psychological issues. Third, this paper will identify Choate’s Body Image 1 This paper will use “body image dissatisfaction” and “body dissatisfaction” interchange- ably. 2 | COLUMBIA SOCIAL WORK REVIEW, VOL. X BODY IMAGE RESILIENCE PROGRAM Resilience Model (2005) as a strengths-based model that implicitly draws on sociocultural theories of body image dissatisfaction to help girls to develop positive body image—and in doing so, help them to understand and address body dissatisfaction—on an individual or community basis. Finally, and most importantly, this paper will propose a prevention-intervention program for developing body image resilience, grounded in Choate’s Body Image Resilience Model, engaging adolescent girls in dance movement therapy (DMT) and their families in discussion of body image issues. We posit that this should be a preferred intervention to address body image dissatisfaction in the target population in school- or community-based settings. It is argued that addressing body image dissatisfaction in this way could reduce the risk of development of maladaptive eating behaviors and other psychological symptoms. THE RISE OF BODY IMAGE DISSATISFACTION Given the negative effects of body image dissatisfaction, its causes should be explored. Multiple explanations for the rise of body dissatisfaction in adolescent populations have been proposed. For example, Vartanian and colleagues (2018) theorized a link between body image dissatisfaction and adverse life events, lower self-concept, and greater internalization of appearance. However, the primary explanation for body image dissatisfaction that has been tested in middle-school-aged girls is sociocultural. That is, body image dissatisfaction is associated with the dominant culture’s promoted imagery of the idealized thin and, at times, sexualized female body. Taking a sociocultural perspective, Thompson, Heinberg, Altabe, and Tantleff-Dunn (1999) propose a Tripartite Model of Influence in relation to body dissatisfaction, consisting of the media, peers, and parents. These three influences are mediated through internalization of the thin-ideal and appearance comparison processes. Keery, van den Berg, and Thompson (2004) tested this model on a sample of middle-school-aged girls. Keery et al. (2004) found a causative link between the media, peers, and parents’ influences and body image dissatisfaction in this population. In the case of parental influence, this relationship was fully mediated by internalization and appearance comparison. In the case of the media and peer influences, internalization and appearance comparison partially mediated the causative relationship. These results were replicated by Schroff and Thompson (2011) with a similar sample. Peers model appearance norms and play roles in formative conversations about appearance, including those about dieting (Jones, 2004; Schroff & Thompson, 2011). The frequency of these conversations about appearance is causatively linked to an increase in body image dissatisfaction, particularly in adolescent females (Clark & Tiggemann, 2006; Jones et al. 2004). In addition, appearance-based teasing and criticism can also cause COLUMBIA SOCIAL WORK REVIEW, VOL. X | 3 BODY IMAGE RESILIENCE PROGRAM body dissatisfaction (Lawler & Nixon, 2011). Teasing and criticism are particularly influential because they apply the sociocultural ideal directly to the individual, which contributes to the process of internalization (Lawler & Nixon, 2011). In relation to parents, it has been theorized that the family’s appearance- related culture, that is, the way thinness, eating, and weight are addressed in family contexts, is linked to body image dissatisfaction (Kluck, 2010). The impact of parents is observed in multiple domains. First, comments about appearance and expressed attitudes about body size influence children. These comments are impactful regardless of whether they are made in relation to the specific child’s body in the form of criticism or teasing, or to bodies generally (Kluck, 2010). Second, parents may influence their children by modeling appearance-related behaviors such as dieting or preoccupation with weight and shape, or by encouraging their children to engage in these behaviors (Kluck, 2010). Research has shown that daughters who are encouraged to diet by their mothers are more likely to be dissatisfied with their bodies (Benedikt, Wertheim, & Love, 1998). In addition, body image dissatisfaction in mothers is linked to body image dissatisfaction in daughters (Kichler & Crowther, 2001). Within the Tripartite Model of Influence, the media is theorized to have the most influence on adolescent body image (Levine & Smolak, 1996). The media portrays an often unattainable standard of thinness (Hargreaves & Tiggemann, 2004). Studies show that the more adolescent girls are exposed to magazines and television, the higher their rates of body dissatisfaction are likely to be over time (Anderson, Huston, Schmitt, Linebarger, & Wright, 2001; Bell & Dittmar, 2011). Outside of the traditional mass media, use of the internet is correlated to body image concerns, particularly when social networking sites are used (Tiggemann & Slater, 2013). Part of the reason that middle-school-aged girls are more at risk of body image dissatisfaction may be the amount of time they spend on social media sites and applications that contain images of celebrities, “influencers,” and peers portraying idealized body types (Perloff, 2014). These images create “exponentially more opportunities for social comparison and dysfunctional surveillance of pictures of disliked body parts than were ever available with the conventional mass media” (Perloff, 2014, p. 366). Essentially, the use of social media by middle-school-aged girls means social comparisons can be made quickly, easily, and against multiple sources (Myers & Crowther, 2009). That is, social media amplifies the thin-ideal that existed already in the dominant culture and that had been created, in part, by mass media. The role of social media in exacerbating the body image dissatisfaction problem underscores the need for proactive efforts to build girls’ body self-esteem—because their social media use seems only to be rising (Anderson & Jiang, 2018). 4 | COLUMBIA SOCIAL WORK REVIEW, VOL. X BODY IMAGE RESILIENCE PROGRAM CURRENT APPROACHES TO PREVENTION AND INTERVENTION Programs aiming to address body image dissatisfaction in adolescents are targeted (focused on those at risk of disordered eating or other adverse outcomes due to high levels of body dissatisfaction), selective (focusing on demographically high-risk populations such as adolescents or girls), or more universal (applied generally to non-symptomatic participants) (Neumark- Sztainer et al., 2006). In a meta-analysis of published prevention trials, it was found that targeted interventions tend to be more effective than universal interventions (Stice, Shaw, & Marti, 2007). Interventions that are interactive and delivered in multiple sessions also have a stronger evidence base (Stice et al., 2007). In the domain of targeted and selective interventions, cognitive behavioral programs, psychoeducation, and dissonance reduction have proven effective (Levine & Smolak, 2006). However, a review of these interventions revealed that, in populations exhibiting body image concerns, the balance of the evidence supports interventions targeting cognitive dissonance (Stice, Shaw, Burton, & Wade, 2006). This approach takes a sociocultural perspective. Dissonance reduction interventions require adolescent girls to critique negative body image beliefs acquired from peer, familial, and media influences through involvement with verbal, written, and behavioral exercises (Stice, Rohde, Gau, & Shaw, 2009). These techniques have resulted in reduction in thin-ideal internalization, body dissatisfaction, dieting attempts, and eating disorder symptoms, persisting through 1-year follow-up (Stice et al., 2009). The evidence supporting dissonance reduction interventions has led to these approaches being labeled the “gold standard” prevention approach, which targets the Tripartite Influence Model (Atkinson & Wade, 2015). Meta-analysis reveals that dissonance interventions are one of only two prevention approaches proven to reduce risk of development of eating disorder pathology at 3-year follow-up (the other being an intervention focused on maintaining healthy weight and not specifically targeting body image dissatisfaction) (Stice, Becker, & Yokum, 2013). Because of the proven effectiveness of dissonance reduction interventions in targeted populations, it is useful to consider whether this approach could be taken in a universal sample. In a randomized controlled trial, Atkinson and Wade (2015) compared dissonance reduction interventions to a mindfulness approach in a sample of adolescent girls. Importantly, the study was applied to a universal sample, containing participants of all levels of body image concern. The mindfulness approach aimed to address sociocultural factors by teaching participants to refrain from automatically responding to the thin-ideal, while simultaneously reducing the impact of negative affect. Negative affect is a risk factor for eating-related dysfunction, thought to coexist with body dissatisfaction COLUMBIA SOCIAL WORK REVIEW, VOL. X | 5 BODY IMAGE RESILIENCE PROGRAM (Atkinson & Wade, 2015). Mindfulness interventions resulted in significant reductions in weight/shape concerns, dietary restraint, thin-ideal internalization, eating disorder symptoms, and psychosocial impairment, when delivered by optimally trained facilitators. However, no significant difference was observed between the group receiving the mindfulness intervention and the group receiving the dissonance reduction intervention. The study indicates that both mindfulness and dissonance- based interventions can be helpful in reducing body dissatisfaction in a universal sample of adolescent girls (Atkinson & Wade, 2015). INDIVIDUAL PROTECTIVE FACTORS: A STRENGTHS-BASED MODEL While most researchers have chosen to focus on the risk factors for body image problems (as well as risk factors for clinically diagnosable eating disorders), a few have identified those strengths that allow women and girls to maintain a healthy body image. We will pair the conceptualization of body image issues and interventions found in existing research with Choate’s (2005) breakdown of risk factors and protective factors for body image challenges in order to move toward an intervention that can be used by educators, social workers, and other concerned professionals in both clinical and nonclinical settings. Choate (2005) acknowledges that women and girls experience pressures as a result of comparison to media representations and their peers. Yet she does not find that all groups encounter these pressures to the same degree or in the same way. While acknowledging that eating disorder and body image dissatisfaction rates do not differ substantially among Asian, Hispanic, and White Americans according to many studies, she points to the African American community as one in which women are “buffered” somewhat from the pressure to have an extremely thin physique (Choate, 2005).2 Warren, Gleaves, Cepeda-Benito, Fernandez, and Rodriguez-Ruiz (2005) point to a possible psychological pathway for such a buffering effect, at least among their Mexican American and Spanish study participants. They identify the adoption of Westernized, thinness-idealizing culture and media as having two components: awareness of the thinness ideals and internalization of those ideals, where internalization is expressed through endorsement and emulation (Warren et al., 2005). They suggest that ethnicity mediates the latter component. Mexican American and Spanish women were found to be significantly less likely to internalize the thin- 2 Research published since Laura Hensley Choate developed her theorization of body image resilience has complicated the narrative somewhat. New studies have found that rates of eating disorders among African Americans do not differ substantially from other groups, or that different groups are prone to different types of eating disorders. See Smink, van Hoeken, & Hoek (2012) for a discussion of general epidemiology between different groups; Shuttlesworth & Zotter (2011) for a discussion of possibly higher binge eating disorder rates among African Americans; Hoek (2016) for a cross-national perspective and review of the literature; and Watson et al. (2013) for a discussion of how Black women still internalize the expectations of the dominant White culture despite having some distance from it. 6 | COLUMBIA SOCIAL WORK REVIEW, VOL. X BODY IMAGE RESILIENCE PROGRAM ideal, and in turn significantly less likely to experience body dissatisfaction (Warren et al., 2005). Psychological pathways are complemented by sociological ones. Non- White or non-northern-European-descent groups’ position outside the dominant White culture is understood to give these groups the ability to more critically evaluate media containing White standards of beauty and to develop their own standards of beauty (Choate, 2005). Family, peer, and community relationships (especially those between mothers and daughters) reinforce the deviations from the dominant culture and facilitate girls’ sense of self-esteem, strength, and independence (Choate, 2005; Parker et al., 1995). The curse of marginalization and racism would seem to have the positive collateral effect of allowing communities to develop or maintain their own norms, insights, and practices that can be healthier than those of the dominant culture. Choate ultimately identifies “(a) family-of-origin support, (b) gender role satisfaction, (c) positive physical self-concept, (d) effective coping strategies, and (e) sense of holistic balance and wellness” as the key protective factors for body image resilience in women and girls (Choate, 2005, p. 325). Snapp, Choate, and Ryu (2012) measured the efficacy of a version of Choate’s Body Image Resilience Model in a survey study of 301 first-year college females. They found marginal or moderate, but mostly statistically significant, correlations between the different protective factors and “overall wellness,” which they measured using Adams et al.’s (1997) Perceived Wellness Survey (Snapp et al., 2012). In turn, they found a .31 positive correlation between wellness and body image, which was measured using the Body-Esteem (BE)-Appearance Subscale of the BE Scale for Adolescents and Adults (Snapp et al. 2012; see Mendelson et al., 2001, for the Body-Esteem (BE)-Appearance Subscale). Other researchers have individually identified the efficacy of each of Choate’s (2005) protective factors (if not necessarily with reference to Choate). Barker and Galambos (2003) confirm the importance of family support. Other researchers refer to self-esteem (O’Dea, 2010), various forms of physical and holistic wellbeing (Shisslak & Crago, 2001); and self- efficacy as protective factors (Shisslak & Crago, 2011; see also Pelletier, Dion, & Lévesque, 2004, who refer specifically to the importance of self- determination as a protective factor against media). Given this broad base of support for Choate’s Body Image Resilience Model, this paper will use it as a touchstone for designing and evaluating the DMT intervention developed therein. COLUMBIA SOCIAL WORK REVIEW, VOL. X | 7 BODY IMAGE RESILIENCE PROGRAM DANCE FOR LIFE: A STRENGTHS-BASED INTERVENTION FOR BODY IMAGE RESILIENCE While Atkinson and Wade (2015), among others, have considered empirically supported interventions to address body image dissatisfaction, their approaches are nonetheless limited in that they fail to adequately incorporate protective factors. We propose a program of school- or community-based Dance Movement Therapy (DMT) that could serve both as a intervention for adolescent girls with body image issues and as a preventative measure for those who do not currently have body image issues but are at risk due to age or demographic factors. Given that parents play a crucial role in their daughters’ body image satisfaction levels, per the Tripartite Model of Influence, Dance for Life would also ideally involve families in a discussion of body image, paired with the DMT sessions and/ or recitals. And while the program would largely shift away from the risk- factors focus of past treatments and toward a strengths-based model, it would also adopt some of the empirically supported, transferable qualities of past interventions, especially the quality of it occurring over multiple sessions (see Stice et al., 2007). We call this program “Dance for Life.” Dance Movement Therapy (DMT) modalities have been used since at least the 1950s (Berrol, 1990). While the pairing of DMT with Choate’s Body Image Resilience Model is new, the idea that various forms of physical activity can promote positive body image is not. Versions of the idea appear in many conceptual articles and small-scale studies. Choate (2005) herself describes exercise and athleticism as promoting the physical self-concept that in turn promotes healthy body image in her model. Pylvänäinen (2003) proposes a model for understanding body image in the context of dance/movement therapy. Lewis and Scannell (1995) find a positive relationship between experience with “creative dance movement” and approval of one’s body among 112 study participants. In a meta-analysis of the literature on dance and movement therapies, Ritter and Graff Low (1996) describe some positive associations between the therapies and body awareness and acceptance. DMT modalities typically include music, movement, and sensory stimulation (Welling, 2014). They can take the form of free-flowing modern dance or expressive, unspecific motion used as nonverbal communication or the basis of a therapeutic alliance (Meekums, 1992). Dance movement therapists adjust the styles and exercises to the group or individual being served (Welling, 2014).3 Figure 1 contains the Program Logic Model (PLM) for Dance for Life. The PLM serves as a visual aid to map out the program intervention, addresses the need for the development of the program, and illustrates program inputs (i.e. treatments) in relation to desired outcomes for the participants. 3 For a comprehensive description of traditional DMT, please see Payne ed. (1992). See Ha- gensen (2015) and Green and Drewes eds. (2014) for DMT with adolescents. 8 | COLUMBIA SOCIAL WORK REVIEW, VOL. X BODY IMAGE RESILIENCE PROGRAM Figure 1. Program Logic Model for the Dance For Life Program Brief Program Description: School- or community-based dance movement program for girls to promote healthful body self-reflection. This program would aim to engage girls to promote healthy physical expression of self and self-love, per the process described by Choate’s Body Image Resilience Model and the tenets of DMT. Problem/Need: Girls could benefit from implementation of a positive youth-development program to help mitigate the risk of social, emotional, and psychological decline associated with body image dissatisfaction. Goals: Tackling sociocultural influences on body image dissatisfaction and promoting body image resilience. Objectives: Using the activity-based youth development program of dancing, groups, and family support to build body image resilience. Inputs Outputs Outcomes Impact Group Counselors or Volunteers Available space for activities Curricula and/ or prompts for dance therapy sessions and family discussion groups Screening tools for assessments Funding source Providers Social workers Volunteer and Group counselors to facilitate Dance Movement Therapy (DMT) groups Participants Adolescent girls and their families Improved health and wellness Reduction in body image dissatisfaction Familial support for and engagement with positive body image and general wellness While dance as a practice allows people to express themselves through healthy movement, Dance for Life as a program goes one step further and allows adolescent girls—with the assistance of social workers, other professionals, and the girls’ own families—to build a community and a space for self-love that might be slightly buffered from the pressures of the dominant culture. Programmatic DMT utilizes not only Choate’s protective factors, but other researchers’ understandings of the psychological and sociological pathways that enable those factors. As noted in the preceding section, researchers have identified marginalization and, by extension, racism as the social forces that enable communities and individuals to build COLUMBIA SOCIAL WORK REVIEW, VOL. X | 9 BODY IMAGE RESILIENCE PROGRAM cultures that reject dominant norms, such as the thin-ideal. Something as destructive as racial segregation, though, need not be the mechanism for the development of separate cultures where positive body image can flourish. Dance for Life would ideally give girls an ideological and communal space where they could cultivate their own norms for wellness, beauty, and self- love. While some of these outcomes of Dance for Life are intangible, certain measures could be used to ensure that Dance for Life implementations are following best practices. We would recommend using a process evaluation to ensure that the program curriculum is being implemented in accordance with Choate’s Body Image Resilience Model (2005). Specifically, the program would be evaluated on: a) how the program is run; b) whether the services are of high quality; c) whether the program is meeting its targets; d) whether the operations are compliant with applicable regulations and mandates; and e) whether clients are satisfied with the services. Program administrators could use a focus group to gather this information. Providers could also implement an impact evaluation for all participants, including adolescent girls and their parents. In short, the program would be evaluated based on achievement of the expected outcomes, the impact of the program on the welfare of the adolescents, and whether the program, in fact, promotes resilience towards the development of negative body image. CONCLUSION As a risk factor for eating disorders and depression, body image dissatisfaction is a serious individual and societal problem, especially for girls and adolescents. (We would recommend that more research be conducted to discern the forms that body image dissatisfaction takes in men, boys, and nonbinary individuals, even if those forms may be attenuated in the two former groups.) While individual characteristics have a role in making a young woman prone to body image dissatisfaction, we initially place body image dissatisfaction into its sociocultural context, identifying the role of peers, family, and the media in a Tripartite Model of Influence. We turn toward the individual and personal protective factors, though, when we discuss not just preventing and intervening with body image dissatisfaction, but promoting positive body image. This focus on the individual and her resilience reflects the reality that changing culture such that it promotes body image satisfaction is hard—especially when such a change would target attitudes as diffuse and universal as those that cause body image dissatisfaction. Choate (2005) and other researchers point to different ethno-racial cultures that have been resilient to White, Westernized standards of thinness and beauty, especially African Americans and Mexican Americans. We duly identify separation from and creation of a socio-ideological space outside the dominant culture as a key pathway for resilience to develop. We adopt Choate’s (2005) model of body image resilience, which identifies five key protective factors, as the goal of our 10 | COLUMBIA SOCIAL WORK REVIEW, VOL. X BODY IMAGE RESILIENCE PROGRAM intervention. We operate with the assumption that protective factors involving physicality and coping strategies are the easiest to develop in adolescent girls. Several empirically supported techniques exist for the treatment of body image dissatisfaction, with dissonance reduction being the most effective. The drawback of these modalities, though, is that these interventions focus largely on risk factors to the expense of protective factors. As an alternative or complement to existing therapies, we put forward Dance Movement Therapy (DMT) as a preventative and interventional program to help girls to develop body image satisfaction, along with resilience toward forces that effectively promote body image dissatisfaction. Our Dance for Life program would use a strengths-based approach to help girls; it would give them the tools that they need to have healthy body image and the space to develop those tools. Versions of DMT have been tried broadly within different outpatient and inpatient psychological programs, to address everything from depression to trauma to eating disorders. We believe that as a flexible, arts-based approach, it would fit in well with the span of activities on which many girls spend their time—where those activities include school, extracurriculars, or hanging out with friends. We provide a general template that clinicians, educators, community members, school administrators, or other concerned parties might use to begin implementing a DMT program for body image dissatisfaction. We further propose that body-image-targeting DMT programs for adolescent girls would be accompanied by family discussion series, as well as informal family engagement and involvement—given the potential of family to be either a negative influence on body image or a significant protective factor. As an alternative, arts-based therapy, DMT has proven popular but understudied. Given the likely increasing ubiquity of body image dissatisfaction due to social media, researchers, educators, and clinicians should be devoted to exploring new solutions and approaches—especially for diverse populations and for communities not otherwise reached by mental health services. The connection of body image dissatisfaction to eating disorders means that not only could people’s emotional well-being be at stake, but also their lives. COLUMBIA SOCIAL WORK REVIEW, VOL. X | 11 BODY IMAGE RESILIENCE PROGRAM REFERENCES Adams, T., Bezner, J., & Steinhardt, M. (1997). The conceptualization and measurement of perceived wellness: Integrating balance across and within dimensions. American Journal of Health Promotion, 11, 208–218. Anderson, D. R., Huston, A. C., Schmitt, K. L., Linebarger, D. L., & Wright, J. C. (2001). Early childhood television viewing and adolescent behavior: The recontact study. Monographs of the Society for Research in Child Development, 66, 1–146. 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RICHTER, M.A. IN PSYCHOLOGY IN EDUCATION Cora B. Richter is currently in her second year of a Reduced Residency MSW program at Columbia School of Social Work in the Advanced Clinical Social Work Practice track. Originally from New Bedford, Massachusetts, Cora received her Bachelor’s degree from Roger Williams University in 2010 and her M.A. in Psychology in Education from Teachers College, Columbia University in 2012. For the past 4 years, Cora has worked full time for Columbia University Medical Center’s Department of Psychiatry as program coordinator for the Columbia Day program, Lieber Recovery and Rehabilitation Clinic, and Smithers Addiction Center where she will continue on next year for field placement. Cora currently resides in Brooklyn, New York. KIMONE C. COLEY is a student in the Advanced Generalist Practice Program track with a focus in Health, Mental Health, and Disabilities. Kimone earned her Bachelor of Arts degree at Smith College in Massachusetts, where she majored in psychology and minored in applied statistics. Born in Jamaica, Kimone loves to write poetry. BODY IMAGE RESILIENCE PROGRAM