Abstract
Individuals develop coping skills in response to body image distress; however, the degree to which body image improvements are mediated by skill acquisition is unknown. The current study assessed skills-based mediators of CBT-BISC (n = 22) versus enhanced treatment-as-usual (n = 22) for sexual minority men with HIV and body image disturbance. Skills-based mediators included avoidance, appearance fixing, and acceptance and cognitive reappraisal. Results revealed that CBT-BISC significantly reduced body image disturbance and improved coping skills. Latent difference score mediation indicated that changes in acceptance and cognitive reappraisal significantly predicted body image disturbance changes (b = −.96, p = .001). These strategies may, therefore, have a unique role in reducing body image disturbance in sexual minority men with HIV. Clinicians may wish to prioritize these strategies in CBT-BISC. Future treatment research, with methodologically rigorous mediation designs, is needed to assess mechanisms of change and consequently improve efficacy.
Similar content being viewed by others
References
Blashill, A. J., Goshe, B. M., Robbins, G. K., Mayer, K. H., & Safren, S. A. (2014). Body image disturbance and health behaviors among sexual minority men living with HIV. Health Psychology,33, 677–680. https://doi.org/10.1037/hea0000081.
Blashill, A. J., Safren, S. A., Wilhelm, S., Jampel, J., Taylor, S. W., O’Cleirigh, C., et al. (2017). Cognitive behavioral therapy for body image and self-care (CBT-BISC) in sexual minority men living with HIV: A randomized controlled trial. Health Psychology,36, 937–946. https://doi.org/10.1037/hea0000505.
Butters, J. W., & Cash, T. F. (1987). Cognitive-behavioral treatment of women’s body-image dissatisfaction. Journal of Consulting and Clinical Psychology,55, 889–897. https://doi.org/10.1037/0022-006X.55.6.889.
Cash, T. F. (2002). Cognitive-behavioral perspectives on body image. In T. F. Cash & T. Pruzinsky (Eds.), Body image: A handbook of theory, research, and clinical practice (pp. 38–46). New York: Guilford Press.
Cash, T. F., & Grasso, K. (2005). The norms and stability of new measures of the multidimensional body image construct. Body Image,2, 199–203. https://doi.org/10.1016/j.bodyim.2005.03.007.
Cash, T. F., Phillips, K. A., Santos, M. T., & Hrabosky, J. I. (2004). Measuring “negative body image”: Validation of the body image disturbance questionnaire in a nonclinical population. Body Image,1, 363–372. https://doi.org/10.1016/j.bodyim.2004.10.001.
Cash, T. F., Santos, M. T., & Williams, E. F. (2005). Coping with body-image threats and challenges: Validation of the body image coping strategies inventory. Journal of Psychosomatic Research,58, 190–199. https://doi.org/10.1016/j.jpsychores.2004.07.008.
Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. New York: Guilford Press.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. (2002). Structured clinical interview for DSM-IV-TR axis I disorders, research version, patient edition (SCID-I/P). New York: New York State Psychiatric Institute Biometrics Research.
Frederick, D. A., & Essayli, J. H. (2016). Male body image: The roles of sexual orientation and body mass index across five national US Studies. Psychology of Men and Masculinity,17, 336–351. https://doi.org/10.1037/men0000031.
Goldin, P. R., Ziv, M., Jazaieri, H., Werner, K., Kraemer, H., Heimberg, R. G., et al. (2012). Cognitive reappraisal self-efficacy mediates the effects of individual cognitive-behavioral therapy for social anxiety disorder. Journal of Consulting and Clinical Psychology,80, 1034–1040. https://doi.org/10.1037/a0028555.
Hansen, W. B., & McNeal, R. B., Jr. (1996). The law of maximum expected potential effect: Constraints placed on program effectiveness by mediator relationships. Health Education Research, 11, 501–507. https://doi.org/10.1093/her/11.4.501.
Harrison, A., de la Cruz, L. F., Enander, J., Radua, J., & Mataix-Cols, D. (2016). Cognitive-behavioral therapy for body dysmorphic disorder: A systematic review and meta-analysis of randomized controlled trials. Clinical Psychology Review,48, 43–51. https://doi.org/10.1016/j.cpr.2016.05.007.
Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling,6, 1–55. https://doi.org/10.1080/10705519909540118.
Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry,61, 348–358. https://doi.org/10.1016/j.biopsych.2006.03.040.
Jarry, J. L., & Ip, K. (2005). The effectiveness of stand-alone cognitive-behavioural therapy for body image: A meta-analysis. Body Image,2, 317–331. https://doi.org/10.1016/j.bodyim.2005.10.001.
Juarascio, A., Shaw, J., Forman, E., Timko, C. A., Herbert, J., Butryn, M., et al. (2013). Acceptance and commitment therapy as a novel treatment for eating disorders: An initial test of efficacy and mediation. Behavior Modification,37, 459–489. https://doi.org/10.1177/0145445513478633.
Kaufman, N. K., Rohde, P., Seeley, J. R., Clarke, G. N., & Stice, E. (2005). Potential mediators of cognitive-behavioral therapy for adolescents with comorbid major depression and conduct disorder. Journal of Consulting and Clinical Psychology,73, 38–46. https://doi.org/10.1037/0022-006X.73.1.38.
Kazdin, A. E. (2007). Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology,3, 1–27. https://doi.org/10.1146/annurev.clinpsy.3.022806.091432.
Kelly, J. S., Langdon, D., & Serpell, L. (2009). The phenomenology of body image in men living with HIV. AIDS Care,21, 1560–1567. https://doi.org/10.1080/09540120902923014.
Klein, D. N., Schwartz, J. E., Santiago, N. J., Vivian, D., Vocisano, C., Castonguay, L. G., et al. (2003). Therapeutic alliance in depression treatment: Controlling for prior change and patient characteristics. Journal of Consulting and Clinical Psychology, 71, 997–1006. https://doi.org/10.1037/0022-006X.71.6.997.
Kraemer, H. C., Wilson, G. T., Fairburn, C. G., & Agras, W. S. (2002). Mediators and moderators of treatment effects in randomized clinical trials. Archives of General Psychiatry,59, 877–883. https://doi.org/10.1001/archpsyc.59.10.877.
McLean, C. P., Yeh, R., Rosenfield, D., & Foa, E. B. (2015). Changes in negative cognitions mediate PTSD symptom reductions during client-centered therapy and prolonged exposure for adolescents. Behaviour Research and Therapy,68, 64–69. https://doi.org/10.1016/j.brat.2015.03.008.
Peplau, L. A., Frederick, D. A., Yee, C., Maisel, N., Lever, J., & Ghavami, N. (2009). Body image satisfaction in heterosexual, gay, and lesbian adults. Archives of Sexual Behavior,38, 713–725. https://doi.org/10.1007/s10508-008-9378-1.
Phillips, K. A., Hollander, E., Rasmussen, S. A., & Aronowitz, B. R. (1997). A severity rating scale for body dysmorphic disorder: Development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacology Bulletin, 33, 17–22.
Pinto-Gouveia, J., Carvalho, S. A., Palmeira, L., Castilho, P., Duarte, C., Ferreira, C., et al. (2016). Incorporating psychoeducation, mindfulness and self-compassion in a new programme for binge eating (BEfree): Exploring processes of change. Journal of Health Psychology,24(4), 466–479.
Powers, M. B., de Kleine, R. A., & Smits, J. A. (2017). Core mechanisms of cognitive behavioral therapy for anxiety and depression: A review. Psychiatric Clinics of North America,40, 611–623. https://doi.org/10.1016/j.psc.2017.08.010.
Preacher, K. J., & Kelley, K. (2011). Effect size measures for mediation models: Quantitative strategies for communicating indirect effects. Psychological Methods, 16, 93–115. https://doi.org/10.1037/a0022658.
Rosen, J. C., & Reiter, J. (1996). Development of the body dysmorphic disorder examination. Behaviour Research and Therapy,34, 755–766. https://doi.org/10.1016/0005-7967(96)00024-1.
Selig, J. P., & Preacher, K. J. (2009). Mediation models for longitudinal data in developmental research. Research in Human Development,6, 144–164. https://doi.org/10.1080/15427600902911247.
Sheehan, D., Lecrubier, Y., Harnett Sheehan, K., Janavs, J., Weiller, E., Keskiner, A., et al. (1997). The validity of the Mini International Neuropsychiatric Interview (MINI) according to the SCID-P and its reliability. European Psychiatry,12, 232–241. https://doi.org/10.1080/09540120600774354.
Smits, J. A., Julian, K., Rosenfield, D., & Powers, M. B. (2012). Threat reappraisal as a mediator of symptom change in cognitive-behavioral treatment of anxiety disorders: A systematic review. Journal of Consulting and Clinical Psychology,80, 624–635. https://doi.org/10.1037/a0028957.
Stears, A., & Hames, C. (2014). Diagnosis and management of lipodystrophy: A practical update. Clinical Lipidology,9, 235–259. https://doi.org/10.2217/clp.14.13.
Su, Y.-J., Carpenter, J. K., Zandberg, L. J., Simpson, H. B., & Foa, E. B. (2016). Cognitive mediation of symptom change in exposure and response prevention for obsessive-compulsive disorder. Behavior Therapy,47, 474–486. https://doi.org/10.1016/j.beth.2016.03.003.
Tylka, T. L., & Andorka, M. J. (2012). Support for an expanded tripartite influence model with gay men. Body Image,9, 57–67. https://doi.org/10.1016/j.bodyim.2011.09.006.
van den Berg, P., Thompson, J. K., Obremski-Brandon, K., & Coovert, M. (2002). The tripartite influence model of body image and eating disturbance. Journal of Psychosomatic Research,53, 1007–1020. https://doi.org/10.1016/S0022-3999(02)00499-3.
Veale, D. (2004). Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image,1, 113–125. https://doi.org/10.1016/S1740-1445(03)00009-3.
Veale, D., Gledhill, L. J., Christodoulou, P., & Hodsoll, J. (2016). Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence. Body Image,18, 168–186. https://doi.org/10.1016/j.bodyim.2016.07.003.
Whisman, M. A. (1993). Mediators and moderators of change in cognitive therapy of depression. Psychological Bulletin, 114, 248–265. https://doi.org/10.1037/0033-2909.114.2.248.
Wilson, G. T., Fairburn, C. C., Agras, W. S., Walsh, B. T., & Kraemer, H. (2002). Cognitive-behavioral therapy for bulimia nervosa: time course and mechanisms of change. Journal of Consulting and Clinical Psychology,70, 267–274. https://doi.org/10.1037/0022-006X.70.2.26.
Acknowledgement
This research was supported by K23MH096647, awarded to Dr. Aaron J. Blashill. Author time for Dr. Steven A. Safren was supported by K24DA040489. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Patrycja Klimek, Sabine Wilhelm, Steven A. Safren, Aaron J. Blashill declare that they have no conflicts of interest.
Research Involving Human and Animal Participants
The current study involved secondary data analysis from a randomized controlled trial approved by the Institutional Review Boards of Fenway Health and San Diego State University. All procedures of the randomized controlled trial involving human participants were in accordance with ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.
Informed Consent
The following study involved a secondary data analysis and was IRB exempt from requiring informed consent, as no identifying information was available for secondary data analysis. However, informed consent was obtained from all individual participants at the time of original data collection.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Klimek, P., Wilhelm, S., Safren, S.A. et al. Cognitive Behavioral Therapy for Body Image and Self-Care (CBT-BISC) Among Sexual Minority Men Living with HIV: Skills-Based Treatment Mediators. Cogn Ther Res 44, 208–215 (2020). https://doi.org/10.1007/s10608-019-10035-w
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10608-019-10035-w