What is mirror exposure therapy?
Mirror exposure therapy is an approach recognised as being effective in reducing body image distress. It can be used as part of a treatment programme for people with eating disorders who experience high levels of body dissatisfaction. This might be expressed in very frequent body checking in the mirror, or in mirror avoidance, due to the high levels of anxiety caused when the individual sees their own image.
Mirror exposure works on the same principle as other forms of exposure therapy: when something provokes overwhelming anxiety, rather than avoiding it, if you are exposed to it in a supported way, you become better able to manage your emotions and over time, anxiety will decrease.
In order to understand how mirror exposure therapy works, we need to explore the concept of body image, which is more complex than it might seem. There are three components of body image: cognitive, which means your perceptions of your body, for example, a person may look in the mirror and see their image own as being much larger than it really is. The affective component means the emotional experience in relation to their body image, for example, a person may experience an overwhelming amount of distress in response to seeing their image in a mirror. The behavioural component describes actions in response to body image, for example, checking a particular body part repeatedly in the mirror to an extent that it becomes a dominating behaviour, or avoiding mirrors to a extreme extent (which perhaps means an individual is unable to go clothes shopping).
There are a range of interventions to help address the thoughts, behaviours and feelings around poor body image, using a cognitive behavioural therapy (CBT) based approach. It is recognised, however, that body image programmes which include mirror exposure therapy are more effective than those which do not (Morgan et al., 2014). This is sometimes described as practical body image, with the practical element of the programme being the mirror exposure. It seems that mirror exposure is very important in helping the individual to tolerate and accept their body at a healthy weight.
At Schoen Clinic Newbridge, we developed the first Practical Body Image Programme for adolescents which has been tested and refined through clinical trials. Mirror exposure is one module of our Practical Body Image programme which is undertaken at the final stage of weight restoration. It is important that young people are more than 90 per cent of a healthy weight because the programme is about accepting your body when you are at a healthy weight (not normalising being underweight).
During mirror exposure therapy, the individual stands in front of a mirror for 30 minutes, wearing tightly fitted clothes. They need to look at the whole body (not ignoring difficult parts or only focusing on one area). Every five minutes, the practitioner will ask the individual to rate the anxiety they are feeling on a scale of 0 to 10. After 30 minutes has passed, the individual is asked to draw a line on a graph showing their anxiety levels. The idea is to support reflection on what increases or decreases anxiety and for the overall experience of exposure to reduce anxiety in the longer term. This is repeated for a further five sessions, occurring twice weekly.
Mirror exposure therapy can be very challenging and it is possible that during the programme, a participant may feel worse before they feel better. Practical body image programmes ask participants to expose themselves to things they find very difficult and scary, but in a supported way with the aim of reducing anxiety overall in the long term. There needs to be careful supervision to monitor anxiety levels and possible changes in weight.
We recognise that some degree of body dissatisfaction is normal and widespread within the general population. Mirror exposure within the Practical Body Image programme is about promoting tolerance and acceptance of the body at a healthy weight which will significantly support the individual in the process of achieving and sustaining recovery from an eating disorder.
Morgan, J. F., et al (2014) Ten session body image therapy: efficacy of a manualised body image therapy, European Eating Disorders Review, 22(1), 66-71.
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