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DEFUSION, THIN IDEAL, BODY IMAGE

The Effects of a Cognitive Defusion Intervention on Body Image, Body-Focused


Anxiety, and Negative Affect After Viewing Ultra-Thin Media Ideals

A Thesis
Submitted to the Faculty
of
Drexel University
by
Renee Mikorski
in partial fulfillment of the
requirements for the degree
of
Masters of Science in Psychology
November 2013

DEFUSION, THIN IDEAL, BODY IMAGE

Copyright 2013
Renee Mikorski. All Rights Reserved.

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Acknowledgements
I would like to thank my advisor Dr. Meghan Butryn for her guidance and support
throughout my thesis project. I would also like to thank Dr. Michael Lowe and Dr. Alix
Timko for serving on my thesis committee.

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Table of Contents
List of Tables .................................................................................................................... vi
List of Figures.................................................................................................................. vii
Abstract........................................................................................................................... viii
1. INTRODUCTION..........................................................................................................1
1.1 Body Dissatisfaction and Normative Discontent.......................................................1
1.2 The Role of the Media..................................................................................................2
1.3 Thin-Ideal Internalization...........................................................................................5
1.4 Consequences of Thin-Ideal Internalization .............................................................5
1.5 Consequences of Body Image Dissatisfaction............................................................6
1.6 Experimental Exposure to Thin-Ideal Images ..........................................................9
1.7 Intervention and Treatment......................................................................................10
1.8 Acceptance-Based Intervention ................................................................................13
1.8.1 Cognitive fusion and its relationship to psychological inflexibility ....................13
1.8.2 Cognitive defusion...................................................................................................15
1.9 Cognitive Defusion Intervention...............................................................................15
1.10 Study Aims and Hypotheses....................................................................................18
2. METHODS ...................................................................................................................19
2.1 Participants.................................................................................................................19
2.2 Procedure....................................................................................................................20
2.2.1 Screening..................................................................................................................20
2.2.2 Random assignment................................................................................................21
2.2.3 Control condition ....................................................................................................21

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2.2.4 Experimental intervention .....................................................................................22


2.2.5 Post-intervention image exposure and assessment. .............................................22
2.2.6 Follow-up image exposure and assessment...........................................................24
2.3 Measures .....................................................................................................................24
3. RESULTS .....................................................................................................................28
3.1 Demographics.............................................................................................................28
3.2 Baseline Differences ...................................................................................................29
3.3 Manipulation Checks.................................................................................................29
3.3.1 Brochure condition .................................................................................................29
3.3.2 Cognitive defusion...................................................................................................29
3.4 Main Effects of the Cognitive Defusion Intervention .............................................30
3.4.1 Differences between body image dissatisfaction, negative affect, and negative
thoughts.............................................................................................................................30
3.4.2 Differences between body-focused anxiety ...........................................................31
3.5 Secondary Analysis ....................................................................................................31
3.5.1 Process variables .....................................................................................................31
3.5.2 Moderating effects of self-esteem ..........................................................................32
3.5.3 Moderating effects of weight-related teasing .......................................................32
3.5.4 Moderating effects of thin-ideal internalization ..................................................32
3.5.5 Moderating effects of BMI .....................................................................................33
3.5.6 Covariation of BMI.................................................................................................33
3.5.7 Covariation of dieting status ..................................................................................33
3.5.8 Covariation of race .................................................................................................33

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4. DISCUSSION ...............................................................................................................34
4.1 Effect of Defusion on Outcome Variables................................................................34
4.2 Effects of Defusion on Process Variables.................................................................36
4.3 Moderating Effects.....................................................................................................38
4.3.1 Thin-ideal internalization.......................................................................................38
4.3.2 Self-esteem ...............................................................................................................38
4.3.3 Weight-related teasing............................................................................................39
4.3.4 BMI...........................................................................................................................39
4.4 Effects of Covariation on Outcome Variables.........................................................40
4.4.1 Current BMI............................................................................................................40
4.4.2 Dieting status ...........................................................................................................40
4.4.3 Race ..........................................................................................................................40
5. LIMITATIONS ............................................................................................................41
6. CONCLUSIONS AND RECOMMENDATIONS.....................................................43
List of References.............................................................................................................46
Appendix A: Copies of Measures ...................................................................................68
Appendix B: Outline of Cognitive Defusion Intervention............................................81

List of Tables

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1. Race and Ethnicity 59


2. Summary of Independent Samples T-tests at Baseline 60
3. Summary of Independent Samples T-tests for the PASTAS ... 61
4. Summary of Interaction Effects of Mixed Between-Within Analysis of
Variance.62

List of Figures

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1. Impact of Cognitive Defusion Intervention on Negative Effects of Exposure


to Thin-Ideal Media Images.. 53
2. Measures Administered Pre- and Post- Intervention and Follow-Up. 54
3. Study Timeline ..... 55
4. Mean PASTAS Scores at Post-Intervention and Follow-Up ... 56
5. Mean EDI- Body Dissatisfaction Scores Over Time .. 57
6. Mean PANAS-Negative Scores Over Time 58

Abstract

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The Effects of a Cognitive Defusion Intervention on Body Image Dissatisfaction, BodyFocused Anxiety and Negative Affect After Viewing Ultra-Thin Media Ideals
Renee Mikorski, B. A.
Meghan L. Butryn, Ph.D.

Body dissatisfaction has become normative among women in the Western world.
The media plays a large role in perpetuating the ideals of beauty for women, which
includes an ultra-thin body, an unattainable standard for most women. Women who
internalize the thin standard of beauty presented in the media are likely to experience
body image dissatisfaction. Current interventions to prevent body image dissatisfaction
include psychoeducation and media literacy, but have been shown to have limited
effectiveness. Cognitive behavioral therapy has also been used to target clinical levels of
body image dissatisfaction, but has not been tested in populations of women with
subclinical levels. Acceptance and Commitment Therapy (ACT) is a new approach in the
cognitive-behavioral tradition, and has a broader focus on feelings, cognitions, and
behaviors, rather than targeting pathology in the individual. Cognitive defusion is a core
component of ACT, and is used to create distance from ones thoughts, a skill which may
be useful in preventing the development of body image dissatisfaction. Therefore, this
study will focus on examining the effectiveness of a cognitive defusion intervention
designed to prevent the development of body image dissatisfaction, body-focused anxiety
and negative affect in college women after viewing images of ultra-thin models.
Participants were randomized to either a control condition or a cognitive defusion
intervention condition and then exposed to images of ultra-thin models. After exposure,
participants were assessed on body image dissatisfaction, body-focused anxiety and
negative affect. It was hypothesized that the participants who receive the cognitive

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defusion intervention would experience lower levels of body image dissatisfaction, bodyfocused anxiety and negative affect after viewing the images, compared to those in the
control group. Participants in the experimental group did report lower levels of body
image dissatisfaction (p = .03), body-focused anxiety (p < .001), and negative affect (p =
.07) after viewing the images, which shows that defusion may be an important variable in
helping young women distance themselves from ultra-thin media ideals. Future research
should focus on tailoring this intervention to meet the needs of racial and sexual minority
individuals to help them distance themselves from racist and homophobic messages they
may see in the media.

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CHAPTER 1: INTRODUCTION
Body Dissatisfaction and Normative Discontent
Body dissatisfaction has become the norm among women in the Western world.
Rodin and colleagues (1984) coined the term normative discontent to describe the way
in which it has become normal for women in Western society to feel unhappy with their
bodies. Many researchers have examined the prevalence of body dissatisfaction in young
women, finding that, on average, 60 % of high school girls and 80 % of college women
express feelings of dissatisfaction with their own bodies (Garner, 1997; Paxton et al.,
1991; Rosen & Gross, 1987). The sociocultural theory of body image dissatisfaction
states that the mass media is an important transmitter and reinforcer of sociocultural body
ideals which have become harder and harder for normal women to achieve (Levine &
Harrison, 2004; Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999).
Rosen and colleagues (1991) describe body image dissatisfaction as the negative
mental image an individual has of the physical appearance of his or her body. Women
who have high levels of body image dissatisfaction have a strong, negative view of their
own bodies. Body image dissatisfaction also involves cognitive disturbances which result
in derision and criticism of the body (Fairburn & Garner, 1986; Garner & Garfinkel,
1981). Higher body mass index (BMI, kg/m 2 ) has been shown to be associated with a
higher level of body image dissatisfaction possibly due to a greater discrepancy between
actual and ideal body shape (McLaren, Hardy, & Kuh, 2003; Tiggemann & Lynch,
2001).

DEFUSION, THIN IDEAL, BODY IMAGE

The Role of the Media


Although the media may not be the only reinforcer of sociocultural body ideals
(as family, friends and peers also have an influence on an individuals perception of a
desirable body shape), the pervasiveness of television and magazines in Western culture
make it one of the most influential and effective promoters of these ideals (Raphael &
Lacey, 1992; Silverstein, Perdue, Peterson, & Kelly, 1986).The current societal standards
for beauty emphasize the importance of thinness and the media often portrays thin
models as happy and virtuous, equating thinness with these traits as well (Striegel-Moore,
McAvay, & Rodin, 1986; Thompson, 1990). These sociocultural ideals reinforce the idea
that body shape and weight are infinitely malleable and are under the control of the
individual, and that obtaining this thin ideal will result in happiness, higher self-esteem
and better health (Brownell, 1991; Thompson et al.,1999).
While the body size of women portrayed in the media has become thinner, the
body size of the average American women has become larger. Spitzer and colleagues
(1999) examined mean BMIs of North American women ages 18-24 who participated in
national health surveys from 1953 to 1991 and compared this data to body sizes of
women in Playboy and Miss America pageants during the same time period. They found
that while the BMIs of North American women increased significantly during this period
of time, the body sizes of the models present in both Playboy and the Miss America
pageants decreased (Spitzer et al., 1999). The number of diet advertisements found in
womens magazines has also increased, with womens magazines containing 10 times
more advertisements and articles about dieting and eating than mens magazines
(Anderson & DiDomenico, 1992). The high prevalence of dieting advertisements in

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womens magazines has also been found in other countries (such as Korea) which have
begun to adopt the Western thin-ideal of beauty (Kim & Lennon, 2006). Another study
conducted in the UK found that food advertisements found in womens magazines had
higher saturated fat, sugar and sodium content than those found in mens magazines
(Adams & White, 2009). This discrepancy further reinforces the societal notion that
women should be focusing on achieving a desirable body shape, even though at the same
time they are being exposed to many advertisements selling unhealthy foods. The most
pervasive and influential media are magazines and television, as models shown through
these mediums are portrayed as accurate representations of real- life people (Ata, Ludden,
& Lally, 2007; Lakoff & Scherr, 1984).
Although it has become harder for women to achieve the slender body sizes of
models in the media, thinness is still regarded as a desirable and attractive characteristic.
In one study conducted by Ahern and Hetherington (2006), undergraduate female
participants were asked to rate different pictures of models as underweight, normal
weight or overweight. Participants labeled many underweight images as normal weight,
implying that women are accepting increasingly thin figures as representing the norm
(Ahern & Hetherington, 2006). Individuals may feel bad about their own bodies when
they are exposed to these unrealistic images of beauty and body size, and feel pressured
to approximate these ideals (Dittmar, 2005).
There are two prominent theories that aim to explain how messages in the mass
media are linked to the development of body image dissatisfaction and eating pathology.
The first is called the Dual Pathway Model, which states that maladaptive messages in
the mass media predispose individuals to eating pathology if the individual has low self-

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esteem, an unstable self-concept and self-perceptions of being overweight (Stice, 1994;


Stice, Nemeroff, & Shaw, 1996; Stice, Schupak-Neuberg, Shaw, & Stein, 1994). When
these maladaptive messages are then reinforced by the individuals family and peers and
continued to be reinforced by the media, the individual feels pressured to control her
weight, often in maladaptive ways. Therefore, the Dual Pathway Model suggests that the
persistent presentation of media messages may be associated with the development of
eating disorders such as bulimia nervosa (Stice, 1994; Stice et al., 1996; Stice et al.,
1994).
The second theory of mass media influence is called the Developmental
Transitions Model and it is based on childhood predispositions to internalize schematic
beliefs about the importance of thinness (Levine & Smolak, 1992; Smolak & Levine,
1994, 1996; Smolak, Levine, & Gralen, 1993). These beliefs are maintained by weight
teasing in childhood and by family and peer modeling of weight concerns. When the
individual reaches adolescence these predispositions may interact with the individuals
reactions to their changing body and social messages about the importance of thinness to
predispose the individual to the development of disordered eating (Levine & Smolak,
1992; Smolak & Levine, 1994, 1996; Smolak et al., 1993).
As the media is so pervasive in Western culture, most young women growing up
in the United States are chronically exposed to sociocultural ideals of body size and shape
(Thompson et al., 1999). Although the pervasiveness of thin-ideal images has been linked
with widespread body dissatisfaction among young women in the United States, not all
women express dissatisfaction with their bodies. This could be because only women who
internalize these media images and actually believe that the women portrayed in the

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media are the way they themselves should look may experience dissatisfaction with their
own bodies when they are not able to emulate this ideal (Stice, 2001).
Thin-Ideal Internalization
Thin-ideal internalization is defined as the extent to which an individual buys
into socially defined ideals of attractiveness and engages in behaviors designed to
approximate those ideals (Ahern & Hetherington, 2006). The media promotes an
unhealthy body image, in which most women seen in magazines and billboards are
visibly underweight (Ahern & Hetherington, 2006). Thin-ideal internalization results
when an individual internalizes ideas or attitudes about weight and body shape promoted
by respected others, including friends, family and the media (Thompson & Stice, 2001).
Specifically, the media reinforces the perpetuation of the thin-ideal through the
glorification of ultra-thin models, therefore influencing those who look to the media for
information on how they should look to internalize this ideal (Thompson & Stice, 2001).
Many experimental studies have explored the construct of thin-ideal internalization, and
have found this construct to be a stable trait, rather than a state (Dittmar, Halliwell, &
Stirling, 2009; Dittmar & Howard, 2004; Heinberg & Thompson, 1995).
Consequences of Thin-Ideal Internalization
Many negative consequences have been associated with internalization of the
thin-ideal. Thin-ideal internalization has been found to be one of the most important risk
factors for the development of eating pathology (Stice & Shaw, 1994). One study
conducted by Stice, Schupak-Neuberg, Shaw, and Stein (1994) showed that
internalization of the thin-ideal was correlated with disordered eating in undergraduate
females. Another study uncovered that individuals with bulimia nervosa showed

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significantly higher levels of thin-ideal internalization, compared to chronic dieters and


healthy controls (Mintz & Betz, 1988). In a study conducted by Kendler et al. (1991),
2,163 female twins were interviewed using an adapted version of the Structured Clinical
Interview for DSM III-R as part of an ongoing study of environmental and genetic risk
factors for common psychiatric disorders. Endorsement of the thin-ideal subsequently
predicted a diagnosis of bulimia nervosa later in life. A prospective cohort study
conducted by Field, Camargo, Taylor, Berkey, and Colditz (1999) assessed 6,982 preadolescent and adolescent girls who, at baseline, reported not engaging in maladaptive
eating behaviors such as vomiting or laxative use in order to control weight. Regardless
of age or stage of puberty, desire to be thinner and to look like models in television or
magazines were both associated with the onset of harmful weight control techniques at
follow-up. Stice (2001) argues that the body dissatisfaction that occurs as a result of thinideal internalization is associated with dieting and negative affect, leading to an onset of
eating pathology. In summary, internalization of the thin-ideal is associated with elevated
risk of eating disorders and body image dissatisfaction.
Consequences of Body Image Dissatisfaction
Body image dissatisfaction has been found to be associated with a variety of
negative outcomes such as the development of negative affect and depressive symptoms
in women (Stice & Bearman, 2001). Stice and Bearman (2001) examined adolescent girls
at baseline, 10-month follow-up, and 20-month follow-up on self-reported BMI, body
dissatisfaction, thin-ideal internalization, perceived pressure to be thin, dieting, and
bulimic symptomatology. They found that initial body dissatisfaction was associated with
increases in dieting, bulimic symptoms and depressive symptoms at both follow-up time

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points. Stice and Shaw (2002) contend that body image dissatisfaction contributes to
negative affect because of the emphasis placed on appearance as an important evaluative
criterion for women in the Western world. Studies have shown that body image
dissatisfaction is not only associated with the development of negative affect in young
women, but also appearance rumination and unnecessary cosmetic surgery (Thompson et
al., 1999).
A direct relationship has also been found between body image dissatisfaction and
the development of bulimic and anorexic symptoms, with some researchers contending it
is the strongest risk factor for the development of eating pathology (Brannan & Petrie,
2008). Graber, Brooks-Gunn, Paikoff, and Warren (1994) conducted a study which
followed adolescent girls over a period of eight years. Participants were assessed at three
time points (mean ages= 14.3, 16.0, and 22.3 years). Those participants who expressed
higher levels of body dissatisfaction at baseline were more likely to report eating
disordered symptoms at the three time points. In a similar longitudinal study, Wertheim,
Koerner, and Paxton (2001) examined eating behaviors, weight-related teasing, selfesteem and depression of adolescent girls in grades 7, 8, and 10 both at baseline and eight
months later. Associations were found in the seventh grade adolescent girls between
initial level of body dissatisfaction and eating pathology eight months later, with higher
initial body dissatisfaction predicting more disordered eating.
Body dissatisfaction has not only been found to be a predictor of the development
of eating pathology, but is also strongly related to relapse for eating disorders (Keel,
Dorer, Franko, Jackson, & Herzog, 2005). Keel, Dorer, Franko, Jackson, and Herzog
(2005) conducted a study in which they assessed individuals with either anorexia or

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bulimia on a semi-annual and then an annual basis on eating disorder symptoms, axis I
disorders, treatment, and psychosocial functioning. They found that participants who
reported greater body image disturbance were more likely to have relapsed, reporting
more eating disorder symptoms at subsequent follow-ups. Even subclinical eating
disturbances such as binging and purging, excessive dieting and a great focus on weight
and eating can occur as a result of high levels of body image dissatisfaction (Lewis &
Cachelin, 2001; Mintz & Betz, 1988; Tylka, 2004; Tylka & Subich, 2002).
An additional factor that may have an influence on the development of eating
pathology due to body image dissatisfaction is body image acceptance. Merwin, Zucker,
Lacy, and Elliot (2010) conducted a study that examined the relationship between
acceptance of affective experience, emotional response clarity and two eating disorder
symptoms: dietary restraint and binge eating. Participants were 50 eating disordered
patients who completed a medical examination, clinical interview and symptom selfreport measures. Non-acceptance (but not lack of emotional clarity) was significantly
associated with dietary restraint symptoms although neither constructs were associated
with binge eating symptoms (Merwin, Zucker, Lacy & Elliot, 2010).
In another study, Merwin et al. (2010) examined control and experiential
avoidance (the opposite of acceptance) as problems that can exacerbate and perpetuate
eating disorder symptoms. Individuals with AN behave as if they are fighting for
complete control over their body and shape, using extreme behaviors such as fasting and
excessive exercise to control their bodys own biological needs (which is something that
ultimately cannot be controlled). This results in a state of biological and emotional
suppression and experiential avoidance, which is a state that is highly reinforcing for

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those who feel the need for certainty and control. Therefore, individuals who have AN
have very high experiential avoidance and very low body acceptance, which could be
associated with the anorexic symptoms that reinforce their need for control.
Timko, England, Herbert and Forman (2010) conducted two studies using the
Implicit Relational Assessment Procedure (IRAP) to examine self-referential beliefs
regarding body image as well as a more general construct of self-esteem in college
females. Positive associations were found between self-referential beliefs on the IRAP
and explicit measures of body satisfaction and acceptance, likelihood of dieting and
internalization of the thin ideal. A correlation was also found between body image
dissatisfaction and higher levels of body acceptance, as well as lower levels of depression
and anxiety. This further reinforces the notion that body acceptance could play a role in
the relationship between body image dissatisfaction and outcomes such as anxiety,
depression and the likelihood of dieting (Timko et al., 2010).
Experimental Exposure to Thin-Ideal Images
In order to establish a direct link between exposure to thin-ideal media images
and body image dissatisfaction, negative affect, and other negative outcomes, many
researchers have conducted experimental studies to explore this relationship. Stice and
Shaw (1994) conducted a study in which female undergraduate participants were
assigned to one of three conditions in which they were exposed to magazine pictures of
either ultra-thin models, average weight models, or no models. The participants who were
exposed to the ultra-thin images reported elevated levels of depression, shame, guilt,
stress and decreased levels of confidence compared to those who viewed the average
weight models or no models. Dittmar, Halliwell, and Stirling (2009) confirmed these

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findings with a similar exposure study in an undergraduate female population, and found
that women who reported high baseline levels of thin-ideal internalization reported higher
levels of negative body-focused affect after exposure to ultra-thin media images,
compared to those who scored lower on thin-ideal internalization. Exposure to thin-ideal
media images causes immediate negative effects, as evidenced by many other similar
studies reporting lower self-esteem, higher levels of body dissatisfaction, negative affect,
and higher levels of body-focused and weight-focused anxiety in undergraduate females
after viewing ultra-thin media ideals (Brown & Dittmar, 2005; Dittmar & Howard, 2004;
Halliwell & Dittmar, 2004; Hawkins, Richards, Granley, & Stein, 2004; Irving,1990;
Posavac, Posavac, & Posavac, 1998; Stice & Shaw, 1994).
These experimental studies further reinforce the immediate harmful effects of
exposure to thin-ideal media images. As body image dissatisfaction is one harmful effect
of viewing thin-ideal media images and has become such a pervasive problem among
young women in Western society, it is important to consider available interventions to
prevent the initial onset of body dissatisfaction or treat it once it has already developed.
Although traditional interventions are designed to target the actual construct of body
image dissatisfaction, others focus on skills that might be important in learning how to
cope with this dissatisfaction while still engaging in behaviors that will allow the
individual to lead a value-driven life (Hayes, Strosahl, & Wilson, 2012).
Intervention and Treatment
Interventions have been developed to strengthen college womens resistance to
media images but have been found to have limited success. These psychoeducational
interventions have focused on media literacy and critiquing and evaluating thin-ideal

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media images (Irving & Berel, 2001). Stormer and Thompson (1995) conducted a study
in which female college students were shown a 30 minute psychoeducational video
informing the audience on techniques used to enhance images of female models to show
that these models are not realistic portrayals of women. The video also taught cognitive
strategies for rejecting the reality of these images. Compared to a control group, these
women did not show significant decreases on measures of body image or eating
pathology after viewing the video. Irving and Berel (2001) conducted a study in which
they assigned female undergraduates to either a media literacy group focused on
critiquing media images, a group which included media literacy and cognitive dissonance
training, and a control group which included watching a video on media literacy. No
significant differences were found between pre- and post-intervention on measures of
body image and negative affect, meaning that none of the interventions were particularly
effective. In order to address the issue of the brevity of these interventions (and test the
hypothesis that a more intensive and lengthy intervention would produce results), RabakWagener, Eickhoff-Shemek, and Kelly-Vance (1998) examined the effects of a foursession, 6.5 hour media analysis intervention and indeed found changes in beliefs and
attitudes related to body image, but not behaviors associated with body image. Also,
because the intervention was much more time intensive, the practicality of dissemination
to a large audience was greatly lessened. Therefore, there is a need to develop practical
interventions which can help young women avoid negative outcomes that occur after
viewing ultra-thin media images.
Therapies have also been developed to treat body image dissatisfaction once
distress reaches a clinical level. One of the most common treatments is cognitive

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behavioral therapy (CBT) developed specifically for body image disturbance by Cash
(1995a, 1995b, 1996, 1997) and Rosen (1996a, 1996b, 1997). This treatment is focused
on developing relaxation skills and exposing the individual to increasingly disturbing
body image situations. Cognitive distortions about the body are then challenged by the
therapist and the client, and maladaptive behavior (including avoidant and obsessivecompulsive behaviors such as body checking) are targeted and modified. The therapist
then encourages the client to engage in body enhancement activities (such as dancing,
bike riding, etc.) and is asked to rate his or her mastery and pleasure for each. The
therapist and the client then work on relapse prevention and the maintenance of positive
changes. It is a traditional cognitive-behavioral protocol in the sense that cognitive
distortions are challenged and positive behaviors are reinforced. Cognitive-behavioral
interventions for body image disturbance have been the most widely documented and
empirically tested approaches and have found to be useful in female college students
(Cash, 1996), obese individuals (Rosen, 1996a, 1996b), and individuals with body
dysmorphic disorder (Neziroglu, McKay, Todaro, & Yaryura-Tobias, 1996; Rosen,
1996a, 1996b).
Although CBT for body image dissatisfaction has been found to be successful for
patients presenting with clinical levels of body image disturbance, the application of CBT
for non-clinical populations may be more challenging. CBT is presented as a whole
package intervention, with a need to use all parts of the therapy in order for it to be
successful (Cash, 1996). Therefore, it would be difficult to disseminate this intervention
in a feasible way to the many women experiencing body image dissatisfaction in Western
society today. Another reason why CBT may not be the best fit for this type of

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intervention is because CBT has only been used and tested in clinical populations. Since
CBT focuses on targeting pathological cognitions and behavior in the individual, (Cash,
1996) it may not be the best fit for a prevention intervention in a non-clinical population.
Acceptance and Commitment Therapy (ACT) is a new approach in the cognitivebehavioral tradition, and has a broader focus on feelings, cognitions, and behaviors,
rather than targeting pathology in the individual (Hayes et al., 2012). This more general
focus on feelings and cognitions may make ACT a better fit for use in non-clinical
populations. Also, because ACT can be broken up into individual exercises (rather than
needing to administer a whole package), it may be a better fit in terms of being able to
disseminate pieces of the intervention to large numbers of people with a smaller burden
to both the individual administering and the individual receiving the intervention. ACT is
based on the notions of mindfulness and acceptance, and is used to enhance
psychological flexibility (Hayes & Smith, 2005).
Acceptance-Based Intervention
ACT includes six core processes, falling under the umbrella of either mindfulness
and acceptance or behavior change and committed action (Hayes, Strosahl, & Wilson,
2012; Pearson, Heffner, & Follette, 2010). These processes focus on developing
psychological flexibility to allow individuals to respond and behave in the present
moment, instead of being tied to and restricted by thoughts that may be occurring in their
mind (Pearson et al., 2010).
Cognitive fusion and its relationship to psychological inflexibility. Cognitive
fusion is a component of psychological inflexibility and occurs when an individuals selfidentity becomes intertwined with the individuals thoughts and concepts of themselves

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(Hayes et al., 2012). Put another way, fusion occurs when an individuals evaluation of
themselves is regarded as an unchangeable truth, causing the individual to become
resistant to changes in these self-concepts. In the context of thin-ideal internalization and
body image dissatisfaction, cognitive fusion can become problematic when an individual
takes sociocultural messages promoted by the media to be part of her self-concept,
believing that she is not thin enough to be attractive, or that her body can never compare
to those of models in magazines and therefore is not acceptable. These sociocultural
messages can be translated into negative thinking about ones own body, which becomes
problematic when the thoughts become intrusive and persistent. This inflexible thinking
can ultimately lead to body image dissatisfaction and negative affect, which may be
especially salient in the presence of thin-ideal media images.
Some studies have shown that individuals who are more accepting and less
avoidant will have less cognitive fusion. There is a societal notion that negative internal
experiences are meant to be controlled or eliminated, which can lead individuals to avoid
or suppress these internal experiences which often leads to detrimental outcomes (Wilson
& Roberts, 2002). Cognitive fusion and experiential avoidance can lead to such behaviors
as obsessive patterns, perfectionism or even eating disordered behaviors (Hayes &
Pankey, 2002). Therefore, ACT focuses on the notion that control strategies are
problematic and the goal should not be to eliminate body image dissatisfaction, but to
accept and defuse from these thoughts and feelings (Heffner, Sperry, Eifert, & Detweiler,
2002).

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Cognitive defusion. Cognitive defusion is a core component of ACT, and is


defined as the ability to separate ones self-identity from the language of selfconceptualization (Hayes et al., 2012). Cognitive defusion helps the individual change the
relationship she has with her thoughts instead of changing the thoughts themselves
(Masuda, Hayes, Sackett, & Twohig, 2004). This causes the individual to make a shift
from looking at the world through literal meaning to a deliteralized look at literal
meaning in order to create a healthy distance between thoughts and reality (Hayes et al.,
2012). Put another way, clients defuse from thoughts by viewing their thoughts as just
thoughts, rather than considering them to have meaning (Blackledge & Hayes, 2001).
As previously outlined, exposure to thin-ideal media images causes the development of
body image dissatisfaction and negative affect, often leading to negative and distorted
cognitions about ones own body shape or self-worth. Cognitive defusion could serve as a
useful tool to help individuals distance themselves from these negative cognitions,
creating a healthy distance between oneself and ones thoughts. This can be achieved by
changing the relationship the individual has with their emotions rather than attempting to
change the emotions themselves.
Cognitive Defusion Intervention
There have been no previous cognitive defusion interventions specifically
conducted to prevent the development of body image dissatisfaction, body-focused
anxiety and negative affect after exposure to ultra-thin media ideals. Because
psychoeducational media literacy interventions have been shown to be ineffective, and
cognitive behavioral treatments have a stronger focus on targeting pathology in the

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individual, there is a need to explore new types of interventions that may yield more
effective results and be more suited for easier dissemination.
Preliminary studies using ACT to treat related problems have shown promising
results (Pearson et al., 2010). Heffner, Sperry, Eifert, and Detweiler (2002) conducted a
case study using ACT for anorexia, incorporating such techniques as the thought parade
(to teach cognitive defusion skills) and the funeral meditation (to clarify values) into the
treatment. The treatment was shown to be effective, with the client showing a reduction
in most anorexic symptoms including decreases in drive for thinness at post treatment.
Masuda, Hayes, Sackett, and Twohig (2004) conducted a study designed to
explore cognitive defusion as a tool that could be used to reduce the believability and
emotion impact of negative self-referential thoughts. Eight undergraduate females were
assigned to either a distraction or cognitive defusion intervention. All participants were
asked to think of a negative self-referential thought and reduce it to one word.
Participants in the distraction condition were then asked to read an article about Japan,
while the individuals in the defusion condition were given a traditional cognitive defusion
rationale and then asked to repeat the negative self-referential word over and over for one
minute (the Milk exercise). All participants were asked to rate the believability and
emotional impact of the words both before and after the intervention. The believability
and emotional impact of negative thoughts in the defusion group were rated lower postintervention compared to the ratings in the distraction group (Masuda et al., 2004).
A similar study was conducted in 2009 by Masuda et al. which found that
repetition of a negative self-referential word for 3 seconds reduced the discomfort (but
not believability) of the word, while repetition of the word for 20 seconds reduced both

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the discomfort and the believability of the word. Therefore, in order to effectively
implement this cognitive defusion exercise, the word needs to be repeated over and over
for at least 20 seconds (Masuda et al., 2009). A similar follow-up study conducted in
2010 by Masuda et al. confirmed these results and again found that the discomfort and
believability of negative self-referential thoughts decreased in the cognitive defusion
condition but not in the distraction condition.
Deacon, Fawzy, Lickel and Wolitzky-Taylor (2011) conducted a study comparing
a cognitive defusion intervention to a cognitive restructuring intervention specifically for
negative self-referential body image thoughts. The cognitive defusion intervention
produced larger reductions in body image concerns immediately following the rationale
and training compared to the cognitive restructuring intervention (which was more of a
traditional cognitive-behavioral approach) (Deacon et al., 2011). Therefore, a cognitive
defusion intervention appears to be a good fit for negative self-referential thoughts
specifically regarding an individuals body image dissatisfaction.
Given that cognitive defusion exercises focus on creating distance between
oneself and one's own negative thoughts, a cognitive defusion exercise may help
individuals gain a new perspective on their thoughts, which in turn could have an effect
on the emotions they experience. As shown in Figure 1, the standard pathway leading to
body image dissatisfaction, body focused anxiety and negative affect involves
internalizing the thin-ideal due to sociocultural presentations of thin-ideal media images.
In turn, acute exposure to these images creates high levels of body image dissatisfaction,
body-focused anxiety and negative affect in individuals who have initially higher levels
of thin-ideal internalization. The intervention will be administered before viewing the

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thin-ideal images, with the expectation that the individuals receiving the intervention will
be given defusion strategies to use when they are exposed to the images.
Study Aims and Hypotheses
The primary aim of the current study was to evaluate a cognitive defusion
intervention in college females who have thin-ideal internalization. It was hypothesized
that the experimental group would report that their negative body image thoughts while
viewing the thin-ideal media images would be less believable and less distressing than
individuals in the control group. It was also hypothesized that the experimental group
would report lower levels of body image dissatisfaction, body-focused anxiety, and
negative affect after viewing thin-ideal media images than the control group.
A secondary aim of the study was to explore baseline levels of thin-ideal
internalization, weight-related teasing, and self-esteem as potential moderators in the
effectiveness of the intervention. Weight-related teasing and self-esteem were included as
potential moderators in order to look at these variables in the context of the
Developmental Transitions Model of the development of body image dissatisfaction
(Levine & Smolak, 1992; Smolak & Levine, 1994, 1996; Smolak, Levine, & Gralen,
1993). It was hypothesized that the cognitive defusion intervention would be more
effective for individuals who have higher levels of thin-ideal internalization, have
experienced higher levels of weight-related teasing, have lower self-esteem and have
perceptions of being overweight. Another secondary aim of the study was to examine
changes in process variables (DDS, BIAAQ, PANAS-Distress) at each time point. As this
study will be performed in a laboratory setting with undergraduate females, it is unclear
whether these findings can be generalized to clinical populations outside of the lab. If

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clinical populations were recruited, there may have been a greater effect on the outcome
variables. Therefore, the findings are considered to be analogue, and may or may not
reflect processes occurring in clinical populations.
CHAPTER 2: METHODS
Participants
Undergraduate females (ages 18-25) were recruited from Drexel University
through the SONA system (an online tool used to recruit undergraduates for psychology
research studies), announcements in psychology courses, and advertisements posted
around campus. The advertisements and announcements emphasized that the study may
be particularly useful for participants who have body image concerns.
An a priori power analysis was conducted for the primary hypothesis to determine
the sample size needed for the study. This analysis was conducted using G Power 3.1.5
(Faul, Erdfelder, Lang, & Buchner, 2007). An effect size of 1.2 was used from the
average of effect sizes in previous cognitive defusion interventions (Masuda et al., 2004,
2009; Deacon et al., 2011). A mixed measures ANOVA was used to compare differences
in pre, post, and follow-up measures in the experimental and the control groups. In order
to calculate the sample size for this test, a medium effect size (f) of 0.25 and a power of
0.80 were used to yield a total sample size of 28.
Eligibility was screened through Qualtrics. Potential participants were considered
to be eligible if they were female and were an undergraduate between the ages of 18-25.
Participants must have had a level of thin-ideal internalization in the upper two-thirds of
the college distribution as measured by the Sociocultural Attitudes Towards Appearance
Questionnaire- Internalization Subscale (Thompson, van den berg, Roehrig, Guarda, &

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Heinberg, 2004). The average score for a normal college population is 28.67 and the
standard deviation is 9.83, thus participants who score 23 or higher were eligible
(Calogero, Davis, & Thompson, 2004). Participants could not have had an eating
disorder or have had one in the past. History of eating disorders were assessed by asking
the question Have you currently or have you ever been diagnosed with an eating
disorder?. Participants were screened in Qualtrics, and only after they meet the
eligibility criteria were they able to complete the study. Upon completion of all parts of
the study, participants received the maximum four extra credit points applied to a
psychology course.
Procedure
Screening. Potential participants who were interested in the study were directed
to the appropriate link in SONA. They completed the screening questionnaire (including
the eating disorder question, as well as the SATAQ-3- Internalization subscale) through
Qualtrics. If potential participants were eligible based on their answers to the screening
questions, they were able to continue on to the baseline measures including the
demographic questionnaire, the Dieting and Weight History Questionnaire (DWHQ), the
Rosenberg Self-Esteem Scale (RSE), the EDI Body Dissatisfaction subscale, the
Positive and Negative Affect Scale (PANAS), the Physical Appearance Related Teasing
Scale- Weight/Size Teasing Subscale (PARTS-W/ST), the Body Image Action and
Acceptance Questionnaire (BIAAQ), the negative thoughts exercise and the Drexel
Defusion Scale (DDS). Before participants filled out the screening questions they were
asked to read and electronically sign a consent form allowing them to be screened for
entry into the study. If participants were eligible, they were then asked to read and

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electronically sign a consent form allowing them to enroll in the study. At the end of the
baseline survey, participants were asked to provide contact information and were
presented with four options for group days and times for the following week and asked to
choose which out of the four times that worked for them as well as write in any additional
times that worked for them.
Random assignment. After completing the pre-intervention questionnaires,
participants were randomly assigned to one of two conditions: the cognitive defusion
group or the control group. Random assignment occurred after 10 participants completed
the online questionnaires in order to insure large enough group sizes. Although group
sizes of 12-14 were initially anticipated, due to scheduling conflicts the researcher
reduced the number to 10. In actuality, group attendance ranged from one to five
members.
Control condition. All participants who were assigned to the control condition
were emailed a psychoeducational handout on body image and media literacy. The
psychoeducational brochure included information about the portrayal of beauty in the
mass media, photoshopping techniques used by magazine editors, as well as how media
messages may be linked to body image dissatisfaction in women. The handout was
emailed on the same day that the cognitive defusion groups met, and control participants
were asked to set aside some time during that day to review the materials and complete
the post-intervention questionnaires. Although previous cognitive defusion interventions
have used distraction or thought suppression for the control conditions (Deacon et al.,
2011; Masuda et al., 2004; Masuda et al., 2009), to be consistent with previous exposure
studies, a psychoeducational control group was used.

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Experimental intervention. Participants who were assigned to the experimental


group were asked to come into the lab for an hour and a half session, and to bring their
laptops to the group. The first hour and 15 minutes of the group time was used to teach
cognitive defusion skills, and the last 15 minutes was used to have participants fill out
post-intervention measures on their laptops. The group session was focused on teaching
participants cognitive defusion strategies which can be used to distance themselves from
negative thoughts that may arise after viewing thin-ideal media images. The session
started with introductions and why each participant decided to join the group. The group
leader provided some psychoeducation and media literacy information before explaining
the defusion material, which made up the majority of the session. The group leader
explained what cognitive defusion is and why it could be helpful when participants are
faced with distressing thoughts and then contrasted the experiences of cognitive defusion
and cognitive fusion. The group leader explained the differences between description and
evaluation (and the bad cup metaphor) and how evaluations can cause distressful
thoughts. Finally, the group leader will taught participants defusion exercises, including
the leaves in a stream exercise. A brief outline of the session is included in Appendix C.
Post-intervention image exposure and assessment. Participants in the control
group received a Qualtrics link in the same email which included the body image
handout. The link contained the thin-ideal media images and post-intervention measures
and participants were instructed to fill out the measures immediately after they finished
reading the handout. Participants in the cognitive defusion intervention group viewed the
media images and completed post-intervention measures on their laptops immediately

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following the intervention in the lab setting. The post-intervention exposure and measures
took about 15 minutes to complete.
A pilot study was conducted to choose the ultra-thin images that were presented
to participants. Sixty images of models taken from Vogue, Glamour and Cosmopolitan,
as well as images found online were presented as a Qualtrics survey to undergraduate and
graduate psychology students at Drexel, and questions were asked about each model
including whether she appeared to be underweight, normal weight or overweight, how
closely the model represented the ultra-thin ideal, and how attractive the model was.
Twenty pictures (10 for the post-intervention questionnaire and 10 for the follow-up
questionnaire) were selected from the 60, representing underweight models that score
highest on closest approximation to the ultra-thin ideal. The BMI of the models chosen
was ultra-thin compared to the average BMI for height and weight, and not compared to
the average BMI of American women (which is in the overweight range). Participants
were instructed to view each thin-ideal image for a few seconds, as if they were just
flipping through a magazine. After exposure to the images, participants in the
experimental group were asked a follow-up question as to whether they used cognitive
defusion skills while viewing the images. Participants in the control group were asked if
they read the educational brochure and how many minutes they took to read it. Although
it was the goal of the researchers to find racially and ethnically diverse images, there
were not many available. Therefore, the models in the post-intervention exposure were all
Caucasian and only two in the follow-up exposure were ethnic minorities.
Immediately after the image exposure was completed, participants completed the
EDI-Body Dissatisfaction Subscale, the Physical Appearance State and Trait Anxiety

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Scale- State version (PASTAS), the PANAS, the BIAAQ, the negative thoughts exercise
and the DDS.
Follow-up image exposure and assessment. All participants were emailed
another Qualtrics link three days after receiving the intervention. The thin-ideal images
had different models than those viewed immediately after the intervention to reduce any
effects of familiarity the participants may have experienced if they had viewed repeat
images. The EDI-Body Dissatisfaction Subscale, the PASTAS, the PANAS, the BIAAQ,
the negative thoughts exercise and the DDS were re-administered to determine if
differences between groups were observed at follow-up. Although it would be ideal to
follow up with participants at time periods farther out from the intervention point, this
was not be feasible in the context of the resources available for this study. Also, because
it was unknown as to how long the effects of the intervention would last, a shorter
follow-up period was warranted to insure that the effects of the intervention would hold
up for at least a few days.
Measures
Demographics Questionnaire. A demographics questionnaire was administered
to participants, including questions about gender (to confirm that they are female), age,
race, ethnicity, and current height and weight (to calculate BMI).
Dieting and Weight History Questionnaire (DWHQ). The Dieting and Weight
History Questionnaire is an 8-item measure which assesses current and past dieting
status. Sample questions include What is the most you have ever weighed since reaching
your current height? and Are you currently dieting to lose weight or to avoid gaining
weight?. The questionnaire helps to establish whether a participant fits into one of three

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dieting categories: current dieter, historical dieter, or never dieter. These three dieting
categories have been found to be associated with distinct eating behaviors (Lowe et al.,
2006).
Negative Body Image Thoughts. Participants were asked to list three negative
thoughts they have about their bodies. After each thought, the following questions
appeared: How distressing do you find this thought? and How believable do you find
this thought? and participants were asked to rate the level of distress and believability on
a visual analogue Likert scale ranging from 0 (not distressing on the level of distress
scale, and not at all believable on the believability scale) to 100 (very distressing on
the level of distress scale, and very believable on the believability scale) (Masuda et al.,
2004).
Sociocultural Attitudes Towards Appearance Questionnaire Internalization
Subscale (SATAQ-3) (Thompson, van den berg, Roehrig, Guarda, & Heinberg,
2004). The SATAQ-3 Internalization subscale is a 9-item measure which measures the
extent to which an individual buys into societal norms of appearance (Thompson et al.,
2004). The internalization subscale has been shown to be reliable and valid across a
variety of populations, with a Cronbachs alpha of .96 (Thompson et al., 2004). Sample
items include I would like my body to look like the women that appear in TV shows
and I wish I looked like the women pictured in magazines that model underwear
(Thompson & Stice, 2001). Higher scores on the SATAQ-3- Internalization Subscale
indicates a higher level of internalization of the thin-ideal (Thompson & Stice, 2001).

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Rosenberg Self-Esteem Scale (RSE; Rosenberg, 1965). The RSE is a 10-item


scale used as a measure of global self-esteem and general self-worth (Puhl & Brownell,
2006; Vartanian & Shaprow, 2008). Each item is rated on a 4-point scale, ranging from 1
to 4, and higher scores indicate higher global self-esteem (Vartanian & Shaprow, 2008).
Sample items include On the whole I am satisfied with myself and I feel I have a
number of good qualities (Rosenberg, 1965). Previous research has demonstrated
validity and reliability for the RSE (Puhl & Brownell, 2006).
Physical Appearance Related Teasing Scale Weight/Size Teasing Subscale
(PARTS-W/ST; Thompson, Fabian, Moulton, Dunn, & Altabe, 1991). The PARTS is
an 18-item scale with two subscales: Weight/size teasing (W/ST) and General
Appearance Teasing (GAT), which measure weight and appearance teasing, respectively.
The W/ST subscale has been found to converge well with measures of body image
dissatisfaction and eating disturbance (Thompson et al., 1991). Participants are presented
with questions such as When you were a child, did you feel that your peers were staring
at you because you were overweight? and asked to rate how frequently this situation
occurred to them on a Likert scale ranging from 1 (Never) to 5 (Frequently). The PARTS
has been shown to be highly internally consistent and have high test-retest reliability,
with an alpha coefficient of .91 (Thompson et al., 1991).
Positive and Negative Affect Scale (PANAS; Watson, Clark, & Tellegen,
1988). The PANAS is used to assess positive and negative affect that individuals are
experiencing in the moment (Watson et al., 1988). A list of positive and negative
emotions is presented to participants and they are asked to list a number next to the
emotion ranging from 1- very slightly or not at all to 5- extremely (Watson et al.,

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1988). The PANAS has been shown to have high internal consistency and validity, with
Cronbachs alpha scores of .88 for the positive affect scale and .87 for the negative affect
scale (Watson et al., 1988). The question how distressed are you by this emotion? was
added after each negative emotion listed on the scale.
Eating Disorders Inventory- 2 (EDI-2)- Body Dissatisfaction Subscale
(Garner, 1991). The Eating Disorders Inventory-2 is used to assess symptoms of
anorexia nervosa and bulimia nervosa. The body dissatisfaction subscale is an 8-item
scale used to measure the participants attitudes, feelings and behaviors about food,
eating and their bodies. Participants are asked to read a statement and decide if the
statement is true always, usually, often, sometimes, or rarely. Sample items
include I think that my stomach is too big and I think that my thighs are too large.
The EDI-2 has been shown to have good construct validity in both clinical and nonclinical populations, with a Cronbachs alpha of .92 (van Strien & Ouwens, 2003).
Body Image Action and Acceptance Questionnaire (BIAAQ; Sandoz &
Wilson, 2006). The BIAAQ is used to assess experiential avoidance associated
specifically with thoughts about body image. Participants are given statements about
body image and asked to rate how true the statement is on a Likert scale of 1 to 7, with
scores ranging from 1- Never True to 7-Always True. Sample items include
Worrying about my weight makes it difficult for me to live a life that I value and I
care too much about my weight and body shape. The BIAAQ has been shown to be
reliable and valid , with an internal consistency score of .93(Ferriera, Pinto-Gouveia, &
Duarte, 2011). The 12-item version of the scale (which is the more commonly used
version) has a Cronbachs alpha score of .92 (Sandoz, Wilson, Merwin, & Kellum, 2013).

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Physical Appearance State and Trait Anxiety Scale State Version


(PASTAS; Reed, Thompson, Brannick, & Sacco, 1991). The PASTAS is used to
assess body related anxiety and can be administered in a state or trait form (Reed et al.,
1991). The state version was used for this study to measure how participants were feeling
about their bodies in the moment. Body parts are listed on the inventory and participants
are asked to rate how tense, anxious or nervous they feel about certain body parts at that
particular moment, with scores ranging from 0- not at all to 4- exceptionally so
(Reed et al., 1991). The PASTAS has been shown to be highly internally consistent and
has high test-retest reliability in college females (Reed et al., 1991).
Drexel Defusion Scale (DDS; Zebell, Yeomans, Forman, & Moitra, 2006).
The Drexel Defusion Scale is a 10-item scale used to measure psychological distance
from negative thoughts and feelings (Zebell et al., 2006). Higher scores on the DDS
indicate greater ability to defuse from negative thoughts and feelings (Zebell et al., 2006).
CHAPTER 3: RESULTS
Demographics
The present sample included 50 female undergraduates. Twenty five participants
were randomly assigned to the psychoeducational brochure (control) group and 25
participants were assigned to the cognitive defusion training (experimental) group. The
study was powered to detect a small effect with an effect size f=0.1 and total sample size
of n=50 to yield a power value of 0.31. Age, race, and ethnicity data were collected from
all participants (Table 1). Mean age was 19.88 years (SD = 1.60). The majority of
participants identified as Caucasian (65.3%), 26% of participants identified as AsianAmerican, 10.2% of participants identified as Black/African-American, 8.2% of

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participants identified as Other, and 6.1% of participants identified as American Indian.


Most participants identified their ethnicity as Non-Hispanic/Latino (93.9%).
Baseline Differences
Independent samples t-tests were conducted to examine any potential differences
between conditions in scores on psychological outcomes of interest at baseline (e.g.
SATAQ, RSE, PANAS, PARTS, BIAAQ, DDS), as well as mean age and BMI. As
shown in Table 2, no significant differences were found on these measures between the
control and experimental groups at baseline.
Manipulation Checks
Brochure condition. Participants assigned to the brochure condition were asked
to read a brochure on body image that was emailed to them before viewing the images of
the models and completing the post-intervention questionnaires. Participants assigned to
this condition were asked if they read the brochure and how many minutes it took them to
read it. All participants who were assigned to this condition reported reading the
brochure, and the mean for number of minutes spent on reading the brochure was 13.42
(SD = 6.39). Of note, one participant did not respond to this question, and the minimum
number of minutes spent reading the brochure was zero. 100% of control participants
completed both the post-intervention and follow-up measures.
Cognitive defusion. All 25 participants who were assigned to the cognitive
defusion intervention completed the in-person training session. Participants assigned to
this condition were asked to complete the post-intervention questionnaires immediately
following the defusion training (in the research center). After being exposed to the
images and before completing the post-intervention questionnaires, participants were

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asked Did you use the cognitive defusion skills you learned in group while viewing
these images? Seventeen participants (70.8%) answered yes to this question and one
participant did not respond. Participants were also asked the same question at the followup time point three days later. Twenty participants (80%) answered yes to this question
at the follow-up time point. Therefore, the majority of participants endorsed using the
defusion skills while viewing the thin models. 100% of experimental participants
completed both the post-intervention and follow-up measures.
Main Effects of the Cognitive Defusion Intervention
Differences between body image dissatisfaction, negative affect, and negative
thoughts. A mixed between-within subjects analysis of variance (ANOVA) was
conducted to determine the impact of intervention condition on participants EDI,
PANAS (Negative Affect), Negative Thoughts-Distress, and Negative ThoughtsBelievability scores across three time periods (pre-intervention, post-intervention, and
three day follow-up. A significant time-by-condition effect was found for scores on the
EDI (Wilks = .87, F[2,47] = 3.66, p = 0.03, 2=.14). This effect demonstrated that
participants in the cognitive defusion group decreased in body image dissatisfaction over
time, while participants in the control group remained stable in their level of body image
dissatisfaction (see Figure 5). The time-by-condition effect for negative affect showed a
trend toward significance, in that participants in the experimental group also showed
decreases in negative affect over time, while those in the control group remained stable;
(Wilks =.892, F (2,47) = 2.85, p = 0.07, 2 = 0.11) (see Figure 6).There were no
significant effects on negative thoughts-distress score (Wilks = 0.96, F(2,47) = 1.07, p

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31

= 0.35, 2= 0.04) or the negative thoughts-believability score (Wilks = 0.93, F(2,47) =


1.91, p = 0.16, 2= 0.08).
Differences between body-focused anxiety. Because the PASTAS was only
administered at post-intervention and follow-up, independent-samples t-tests were
conducted to examine differences in the scores of participants assigned to the
experimental group versus scores of participants who were assigned to the control group.
As shown in Figure 4, participants in the experimental group reported significantly lower
mean scores of body-focused anxiety (M = 12.56, SD = 7.30) compared to the control
group (M = 18.92, SD = 8.74) at post-intervention (t[47] = -2.71, p = 0.009, two-tailed).
A similar pattern emerged at follow-up, with participants in the experimental group
reporting significantly lower mean scores of body-focused anxiety (M = 10.92, SD =
7.19) than the control group (M = 18.48, SD = 11.14; t[48] = -2.85, p = 0.006).
To be consistent with previous analyses, a mixed model repeated measures
ANOVA was also conducted to examine changes in the PASTAS at each time point. No
significant interaction effects emerged from this analysis (Wilks = .96, F (1 , 49) =
2.25, p = .14, 2 = .04).
Secondary Analysis
Process variables. A mixed model repeated measures ANOVA was conducted to
examine change in the DDS, the BIAAQ, and the PANAS-Distress at each time point.
There were no significant interaction effects for the PANAS-Distress score (Wilks =
0.94, F(2,47) = 1.62, p = 0.21, 2 = 0.06), the DDS (Wilks = 0.93, F(2,47) = 1.76, p =
0.18, 2= 0.07), or the BIAAQ (Wilks = 0.99, F(2,47) = 0.19, p = 0.83, 2 = 0.008). A
mixed model repeated measures ANOVA of the 12 item version of the BIAAQ was also

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conducted with no significant interactions effects (Wilks = .98 F(2, 48) = .39, p= .68,
2 = .02).
Moderating effects of self-esteem. Moderation analyses were conducted to
examine the effects of self-esteem on the effectiveness of the intervention. Different sets
of repeated measures models were conducted using the following predictors: treatment
condition (main effect) and the interaction term between treatment condition and the
moderator (moderated effect). First, an analysis was conducted to examine the effects of
RSE score on body image dissatisfaction (EDI score). Self-esteem showed a moderating
effect on the relationship between condition and body image dissatisfaction (F[2,92] =
3.11, p = 0.049). Participants with higher self-esteem at baseline received greater benefits
from the intervention with respect to body image dissatisfaction, whereas there were no
differences between conditions for participants with lower self-esteem. Self-esteem did
not have a significant moderating effect on negative affect (F[2,92] = 1.52, p = 0.22) or
body-focused anxiety (F[1,46] = 1.66, p = 0.20).
Moderating effects of weight-related teasing. Moderation analyses (as
described above) were conducted to examine the effects of weight-related teasing on the
effectiveness of the intervention. Weight-related teasing did not have a significant
moderating effect on body image dissatisfaction (EDI score; F[2,92] = 0.39, p = 0.68),
negative affect (PANAS-Negative score; F[2,92] = 0.04, p = 0.96), or body-focused
anxiety (PASTAS score; F[1,46] = 0.65, p = 0.43).
Moderating effects of thin-ideal internalization. Moderation analyses (as
described above) were conducted to examine the effects of thin-ideal internalization
(SATAQ score) on the effectiveness of the intervention. Thin-ideal internalization did not

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have a significant moderating effect on body image dissatisfaction (EDI score; F[2,92] =
0.05, p = 0.95), negative affect (PANAS-Negative score; F[2,92] = 1.78, p = 0.17), or
body-focused anxiety (PASTAS score; F[1,46] = 0.43, p = 0.52).
Moderating effects of BMI. Finally, moderation analyses (as described above)
were conducted to examine the effects of participants current BMI on the effectiveness
of the intervention. BMI did not have a significant moderating effect on body image
dissatisfaction (EDI score; F[2, 90]= .49, p = .61), negative affect (PANAS-Negative
score; F[2, 90]= 1.27, p = .29), or body-focused anxiety (PASTAS score; F[1, 45]= 2.07,
p = .15).
Covariation of BMI. A one-way ANCOVA was conducted to examine the
covariance of BMI on the outcome variables. After adjusting for BMI scores, there was a
significant effect on body image dissatisfaction (EDI scores; F[2, 92]= 4.35, p = .015)
and negative affect (PANAS-Negative; F[2, 92] = 3.75, p = .027), not but body-focused
anxiety (PASTAS scores; F[1,47]= .57, p= .45).
Covariation of dieting status. A one-way ANCOVA was conducted to examine
the covariance of dieting status on the outcome variables. After adjusting for dieting
status, there was a significant effect on body image dissatisfaction (EDI scores; F[2, 92]
= 4.03, p = .02), and negative affect (PANAS-Negative; F[ 2, 92] = 5.09, p = .008) but
not body-focused anxiety (PASTAS score; F[1, 47] = .5, p = .75).
Covariation of race. A one-way ANCOVA was conducted to examine the
covariance of race on the outcome variables. After adjusting for race, there was a
significant effect on body image dissatisfaction (EDI scores; F[ 2, 92]= 4.43, p = .01),

DEFUSION, THIN IDEAL, BODY IMAGE

34

and negative affect (PANAS-Negative; F[ 2, 92] = 3.63, p = .03), but not body-focused
anxiety (PASTAS score; F[1, 47]= .10, p = .48).
CHAPTER 4: DISCUSSION
Effect of Defusion on Outcome Variables
The present study demonstrated that a cognitive defusion intervention
significantly buffered the negative effect of exposure to a thin-ideal model on body
dissatisfaction and body-focused anxiety. Compared to participants in the control group,
those who received defusion training had lower levels of body dissatisfaction and bodyfocused anxiety over time. These differences were significant even at three-day followup, indicating that defusion could have a meaningful influence on body image and bodyfocused anxiety beyond the time immediately following intervention. Because cognitive
defusion is a skill that teaches individuals how to see their thoughts as just thoughts, it
can be assumed that the participants who learned these skills were successfully able to
distance themselves from the thin-ideal images and internalization of the ideals these
images promote, as well as any body image dissatisfaction or body-focused anxiety that
would have normally been produced in these individuals after viewing the images.
As past research has shown that exposure to thin-ideal media images can cause a
variety of negative outcomes in college women (Brown & Dittmar, 2005; Dittmar &
Howard, 2004; Halliwell & Dittmar, 2004; Hawkins et al., 2004; Irving, 1990; Posavac et
al., 1998; Stice & Shaw, 1994), it is important to develop an intervention to prevent
women from internalizing these ideals. Previous interventions have focused on media
literacy to help college women buffer the immediate negative effects of these images and
have been proven unsuccessful (Irving & Berel, 2001; Rabak-Wagener et al., 1998;

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35

Stormer & Thompson, 1995). Therefore, cognitive defusion could be an important skill to
teach college women in order to prevent them from internalizing the thin-ideal. Although
the intervention focused on negative body image thoughts rather than feelings, it is clear
that by teaching participants to defuse from these negative thoughts, they were able to
defuse from negative feelings about their bodies as well.
Although the intervention did not produce a significant effect on general negative
affect, the experimental group did show a trend toward lower mean values of negative
affect than the control group after viewing the thin-ideal images. It is possible that this
result did not reach significance due to low power. A second possibility is that the focus
of the intervention was on defusing from specific body-focused thoughts and did not
prevent more general negative affect from arising after viewing the images. In the future,
a more broad intervention that includes skills and strategies for addressing general
negative affect that may arise after viewing the images may lead to a significant result.
Similarly, although the defusion intervention focused on teaching individuals how
to distance themselves from their negative body image thoughts, there was no significant
difference in the believability and distress ratings of negative body image thoughts
between participants in the experimental versus the control group. Therefore, it is
possible that the participants in the experimental group were able to defuse from thinideal messages in general but were unable to defuse from the specific negative body
image thoughts that they were asked to write down at each time point. In the future, the
intervention could be targeted to focus on these particular thoughts and perhaps
participants could be asked to share the thoughts that they wrote down in group in order
to learn how to defuse from specific body image thoughts that are challenging. The focus

DEFUSION, THIN IDEAL, BODY IMAGE

36

on defusing from specific negative thoughts (instead of more general ones) has been
shown to be effective in previous studies (Deacon et al., 2011; Masuda et al., 2004;
Masuda et al., 2009; Masuda et al., 2010).
Effects of Defusion on Process Variables
There were no significant differences in change over time between the
experimental and control groups on three process measures, namely the DDS, the BIAAQ
or the PANAS-Distress scales. The lack of effect on DDS scores is somewhat surprising,
as the DDS is a valid and reliable measure of the ability to use the skill of cognitive
defusion in a variety of different situations (Zebell et al., 2006). It is possible that the
DDS was too broad of a measure to capture the specific cognitive skills that participants
used to distance themselves from these thin-ideal images, and that participants were not
able to apply these skills to different situations besides those that cause them to
experience body image dissatisfaction. Another reason why the DDS may not have been
significant over time is that it may be more of a trait, and not a state, measure of defusion.
Therefore, DDS scores may have remained stable over time even though some
participants were taught defusion skills in the time frame of the study while others were
not taught these skills.
The BIAAQ is a tool used to measure body image acceptance as well as
experiential avoidance regarding ones thoughts and feeling about their body image.
(Sandoz & Wilson, 2006), and it was hypothesized that participants in the experimental
group would report higher levels of body image action and acceptance after receiving the
defusion training. Therefore, it is possible that although participants in the defusion group
were able to defuse from the messages promoted by the thin-ideal images, they were not

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37

able to make the additional step in acceptance of the negative thoughts and feelings about
their bodies. Acceptance of these negative thoughts and feelings could be beneficial for
participants in order to develop an overall positive self-schema which includes
recognition of these negative thoughts and feelings without placing any importance of
them. Additional refinement of the cognitive defusion intervention could add body
acceptance training, which may broaden the observed positive effects (Pearson et al.,
2010).
Given that the intervention showed no effect on the body image thoughts distress
scale, it is not surprising that there also was no effect on the PANAS-Distress scale.
Again, although participants in the experimental group were able to defuse from
messages promoted by the thin-ideal media images, it is possible that they were not able
to defuse from more general negative emotions that they may have been experiencing, in
addition to the distress that these negative emotions may have caused. The PANASDistress scale was created for the purposes of this study and therefore has not been shown
to be reliable and valid. Therefore, it is possible that participants may have shown
differences in their levels of distress surrounding negative emotions they were
experiencing but that the PANAS-Distress scale was not refined enough to capture these
differences.
Lastly, compared to previous interventions designed to reduce body image
dissatisfaction in college women after viewing ultra-thin media ideals, it is possible that
the reason participants did not show a change in process variables could be because there
were nonspecific effects of the intervention rather than defusion being the active
ingredient in the change. Previous studies examining brief 45 minute media literacy

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38

interventions have shown limited success in decreasing body image dissatisfaction and
other negative outcomes (Irving & Berel, 2001). Since about 25% of the current
intervention (~ 19 minutes) was devoted to the discussion of media literacy and thin-ideal
internalization, this could have affected the lack of change in process variables. In the
future, less time could be devoted to media literacy to see if this has an effect on the
process variables.
Moderating Effects
Thin-ideal internalization. Baseline level of thin-ideal internalization did not
have a significant moderating effect on body image dissatisfaction, body-focused anxiety,
or negative affect at post-intervention and follow-up time points. Therefore, all
participants who had moderate or high levels of thin-ideal internalization (greater than 23
on the SATAQ- Internalization subscale) benefitted from the intervention equally. It was
expected that participants who had higher levels of internalization of these messages
would benefit the most from skills that would allow them to distance themselves from
these messages. It is encouraging that the intervention was equally effective for
participants who had moderate or high thin-ideal internalization. This study did not
include participants with low thin-ideal internalization, as they were expected to have had
minimal benefit from cognitive defusion skills.
Self-esteem. Baseline levels of self-esteem moderated the intervention effect on
body image dissatisfaction, but not body-focused anxiety or negative affect, at postintervention and follow-up time points. Among participants with high levels of baseline
self-esteem, there was a significant effect of the intervention. However, among
participants who had lower levels of self-esteem at baseline the intervention had less

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39

benefit, compared to control. This finding did not support the hypothesis that those who
had lower self-esteem at baseline would benefit more from the intervention than those
with higher self-esteem. It is possible that participants with higher self-esteem also had
higher levels of self efficacy and therefore were better at applying the defusion concepts
they learned outside of the intervention session. Previous research has shown that these
two traits are highly correlated (Judge, Erez, Bono & Thoresen, 2002). Therefore, it
would be worthwhile to measure self efficacy along with self-esteem in future studies.
Weight-related teasing. Weight-related teasing did not moderate body image
dissatisfaction, body-focused anxiety, or negative affect at the post-intervention or
follow-up time points. Scores on the PARTS scale can range from 12-60; as the mean
scores on the PARTS were 20.44 for the control group and 20.12 for the experimental
group, participants in this study did not endorse high levels of weight-related teasing (as
measured) (Thompson et al., 1991). This is consistent with mean reported BMI, which
was in the normal range for both the control and experimental groups. If the scores of
weight-related teasing had a greater range, it is possible that this variable could have an
impact on the effectiveness of the intervention. As weight-related teasing has been shown
to be one factor associated with the development of body image dissatisfaction (Stice,
1994; Stice et al., 1996; Stice et al., 1994), defusion skills could be helpful for individuals
who internalize messages from peers, as well as the media, about the ideal body shape.
BMI. Participants current BMI did not moderate the effectiveness of the
intervention. Therefore, participants who had a lower BMI benefitted the same amount
from the intervention as those who had a higher BMI. Although some research shows that
individuals who are overweight or obese are more likely to have increased levels of body

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40

image dissatisfaction, not all overweight or obese individuals are equally susceptible
(Schwartz & Brownell, 2004). Therefore, it is possible that because the levels of thinideal internalization and body image dissatisfaction were similar in individuals with
lower BMIs and those with higher BMIs, this is why all participants benefitted equally
from the intervention.
Effects of Covariation on Outcome Variables
Current BMI. After controlling for participants current BMI, the intervention
still had a significant effect on body-focused anxiety, but not body image dissatisfaction
or negative affect. This could be because body-focused anxiety is a state measurement,
whereas participants body image dissatisfaction is a trait measurement, especially if the
dissatisfaction is related to current BMI. In addition, there could be a relationship
between negative affect and current BMI that the defusion intervention did not target
adequately. As mentioned before, the defusion intervention did not directly target
negative affect and this is possibly why, after controlling for BMI, the intervention still
did not have a significant effect on negative affect.
Dieting status. After controlling for participants dieting status, the intervention
still had a significant effect on body-focused anxiety, but not body image dissatisfaction
or negative affect. Again, this could be due to the fact that body-focused anxiety is a
state rather than a trait. Dieting status is a trait and therefore the intervention may have
only had an effect on those variables that were state-based.
Race. After controlling for participants race, the intervention still had a
significant effect on body-focused anxiety, but not body image dissatisfaction or negative
affect. Again, this could be due to the fact that race is an unchangeable trait and

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41

therefore, when controlling for race, the defusion intervention only had an effect on
body-focused anxiety (a state-based variable).
CHAPTER 5: LIMITATIONS
There are a few important limitations that arise for the present study. First, this
study is unable to separate the differences between body image dissatisfaction and
dissatisfaction about not being able to achieve the beauty ideal in general. Although the
thin ideal is an important part of the beauty standard promoted by society and the media,
other factors such as clear complexion, small nose, and large lips (features traditionally
considered to be attractive) could lead to some of the hypothesized dissatisfaction after
viewing the images of models.
Another limitation that arises is that the study is unable to distinguish between
body image dissatisfaction that may be present due to wanting to be thin vs. a fear of
gaining weight. A study conducted by Chernyak and Lowe (2010) examined the
differences in unrestrained eaters, restrained eaters and individuals with bulimia on
several measures including Drive for Thinness (DFT) on the Eating Disorder Inventory
(EDI), the Drive for Objective Thinness Scale (DFOT), and Goldfarbs Fear of Fat Scale
(GFFS). Restrained eaters scored higher than unrestrained eaters on the DFT subscale
and the GFFS, but both groups scored low on the DFOT compared to individuals with
bulimia. Therefore, individuals who are dieting may restrain their eating to achieve a
lower weight but not necessarily one that would be consistent with achieving the thin
ideal. Individuals who had bulimia were the ones who expressed a desire to be
objectively thin (and reach the societal ideal). The present study (although it will be
excluding individuals who report having a present or past eating disorder) will not be able

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42

to differentiate between body image dissatisfaction due to desire to be thinner, desire to


be objectively thin or fear of fatness or weight gain.
There are some expectancy effects that may have been present throughout the
study. As there was limited time and resources available to conduct the study, not all
participants were able to come into the lab to receive the intervention. Therefore, because
the control group participants received the intervention through email and the
experimental group came into the lab to receive the intervention, those in the
experimental group could be more likely to answer the post-test and follow-up
questionnaires the way they believe the researchers would like them to answer.
Especially since participants in the experimental group filled out the post-intervention
questionnaires in the lab setting, this could have had an effect on how they answered the
questions. Unfortunately, due to the limited time and resources afforded for the study,
this limitation could not have been avoided.
Although groups were intended to be similar in size (12-15 participants), due to
scheduling conflicts, this was not the case. All groups were less than 12 participants and
group sizes were uneven. It is possible that the inequality of group sizes could have lead
to erroneous results because of differences in group processes. It is possible that
participants who were in the smaller groups versus the larger groups could have
benefitted differently from the intervention. Smaller groups allow more one on one
interaction with the group leader, which could be a benefit to participants, but larger
groups allow participants to interact with each other and exchange ideas, which could
also have been a greater benefit to participants in those groups. In the future, more

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43

resources should be allocated to allow for greater ease of scheduling and a higher
incentive for participants to come to group.
Participants were also excluded if they reported a past or current eating disorder.
This exclusion criterion made sense in the context of the current study due to the lack of
resources to accommodate these individuals. In the future it would be reasonable to
include participants who had a history of or were currently diagnosed with an eating
disorder, as these individuals may benefit in particular from this type of intervention.
Another limitation that arose in the context of this study was the fact that
participants were not asked to look at each image for a set amount of time. Participants
were instructed to flip through the images as though they were looking at pages in a
magazine. Therefore, the time that participants looked at the images could have varied
greatly between participants and between images (some participants may have preferred
to look at certain images for longer amounts of time). Therefore, future studies should
instruct participants to look at each image for a set number of time to control for these
effects. There was also no check in place to insure that the control group actually read the
psychoeducational brochure, which could have also had an effect on the results.
Therefore, in the future, a quiz could be administered before the post intervention
measures asking participants about what they read in the brochure to insure that they read
it.
CHAPTER 6: CONCLUSIONS AND RECOMMENDATIONS
Cognitive defusion may be a useful tool for helping individuals distance
themselves from negative body image thoughts and feelings that may be induced after
viewing thin-ideal media images. As these media images are highly prevalent in Western

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44

society and are viewed by many women everyday (Levine & Harrison, 2004; Thompson
et al., 1999), it is important to develop interventions to help women buffer the negative
effects of these images. Although an overall societal change is needed to improve the
body image dissatisfaction of women in the Western world, until that happens, cognitive
defusion could be a helpful tool that allows for increased body satisfaction.
Future studies should test a greater numbers of participants to confirm the
significant results of this study. In order to recruit more participants, and for ease of
completion of the intervention, an online version of the intervention may be adapted in
the future. This would allow potential participants to complete the cognitive defusion
training at home and not introduce the barriers of time and money in traveling to the lab.
Therefore, a greater number of participants would be able to complete the session in a
shorter period of time and at their own pace. Additionally, a meta-analysis conducted in
2008 by Barak, Hen, Nissim, and Shapira examined the effectiveness of internet-based
psychotherapeutic interventions across a variety of conditions and found the effect size of
internet-based therapies to be comparable to those delivered face-to-face. Therefore,
cognitive defusion training around body image dissatisfaction could easily be adapted
into an accessible, online version.
Finally, this intervention could be adapted to address the internalization of
weight-related stigma. In particular, cognitive defusion could be used to help overweight
and obese individuals to distance themselves from stigma they may experience in their
every day lives. Although no previous studies have been conducted to test the
effectiveness of defusion on weight-related stigma, some researchers hypothesize that
weight-related stigma can be considered to be a form of fusion with external prejudices

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45

and that teaching defusion skills could help these individuals distance themselves from
these negative prejudices (Lillis & Hayes, 2007). A small pilot study was conducted in
2005 by Luoma, Kohlenberg, Bunting, and Hayes, looking at the effects of an ACT
intervention on self-stigma in individuals with substance abuse issues. Those who
received the intervention scored lower on measures of self stigma following the
intervention. Therefore, this suggests that ACT in general, and defusion in particular
could be useful tools in combating self stigma in regards to weight-related stigma or the
internalization of other societal prejudices.

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58

FIGURES

Sociocultural
Messages of
Thinness

Thin-Ideal
Internalization

Cognitive
Defusion
Intervention

Exposure to
thin-ideal media
images

Exposure to
thin-ideal media
images

High levels of
Body Image
Dissatisfaction,
Body Focused
Anxiety,
Negative Affect
Low levels of
Body Image
Dissatisfaction,
Body Focused
Anxiety,
Negative Affect

Figure 1. Impact of Cognitive Defusion Intervention on Negative Effects of Exposure to


Thin Ideal Media Images

DEFUSION, THIN IDEAL, BODY IMAGE

Measure

Pre-Intervention

59

Post-Intervention

Follow-up

Demographics
Questionnaire
DWHQ

SATAQ
Internalization
Subscale
RSE

PARTS-W/ST

PANAS

EDI-2- Body
Dissatisfaction
Subscale
PASTAS

BIAAQ

Negative Thoughts
Exercise
DDS

Figure 2. Measures Administered Pre- and Post- Intervention and Follow-up

DEFUSION, THIN IDEAL, BODY IMAGE

60

Screening
(Time 0)

Baseline
(Time 1)

Intervention
(Time 2)

Control
group

SONAEating
disorder
question +
SATAQInternalizatio
n

Emailed
Qualtrics
surveyDemographi
cs, DWHQ,
RSE,
PARTSW/ST, DDS

Experimental
group

SONAEating
disorder
question +
SATAQInternalizatio
n

Emailed
Qualtrics
surveyDemographi
cs, DWHQ,
RSE,
PARTSW/ST, DDS

Emailed body Immediately


image
after viewing
handouts
handouts,
complete
Qualtrics
surveyPANAS,
EDI-Body
Dissatisfactio
n, PASTAS,
DDS
In lab
Immediately
cognitive
after
defusion
completing
training
training,
complete
Qualtrics
survey (in
lab) PANAS,
EDI-Body
Dissatisfactio
n, PASTAS,
DDS

Figure 3. Study timeline

Post-test
(Time 2)

Followup (Time
3)
Three
days after
Time 2repeat
post-test
measures

Three
days after
Time 2repeat
post-test
measures

DEFUSION, THIN IDEAL, BODY IMAGE

20

p < .01**

61

p < .01**

18

Mean PASTAS Score

16
14
12
Brochure

10

Defusion

8
6
4
2
0
Post-Intervention

Follow-Up
Time

Figure 4. Mean PASTAS scores at post-intervention and follow-up (significance level


p<.05).

Mean EDI-Body Dissatisfaction Scores

DEFUSION, THIN IDEAL, BODY IMAGE

31.5
31
30.5
30
29.5
29
28.5
28
27.5
27
26.5
26

62

p = .03 **
Brochure
Defusion

Pre-Intervention

Post-Intervention

Follow-Up

Time

Figure 5. Mean EDI-Body Dissatisfaction scores over time (significance level p < .05)

Total PANAS-Negative Scores

DEFUSION, THIN IDEAL, BODY IMAGE

63

18
16
14
12
10

p = .07

Brochure
Defusion

6
4
2
0
Pre-Intervention

Post-Intervention

Follow-Up

Time

Figure 6. Mean PANAS-Negative scores over time (significance level p < .05)

DEFUSION, THIN IDEAL, BODY IMAGE

64

TABLES

Table 1- Race and Ethnicity


Race
White/Caucasian

n (%)
32 (65.3)

Black/African American

5 (10.2)

American Indian

3 (6.1)

Asian
Pacific Islander

13 (26.0)
0 (0)

Other Race

4 (8.2)

Ethnicity
Hispanic/Latino

3 (6.1)

Non-Hispanic/Latino
46 (93.9)
Note. Participants were given the option to choose more than one race.

DEFUSION, THIN IDEAL, BODY IMAGE

65

Table 2- Summary of Independent Samples T-tests at Baseline


Variable

Control

Experimental

Age

M(SD)
19.96(1.46)

M(SD)
19.80(1.76)

t
-.35

p
.73

BMI

21.47(2.98)

22.79(3.72)

1.34

.19

SATAQ

34.76(5.60)

35(5.56)

.15

.88

RSE

16.32(1.91)

16.04(2.03)

-.50

.62

PANAS(Positive)

26.28(7.62)

28.84(6.99)

1.24

.22

PANAS(Negative)

15.04(5.88)

16.08(5.94)

.62

.54

PANAS(Distress)

13.60(5.91)

13.40(5.50)

-.12

.90

PARTS

20.44(11.46)

20.12(11.28)

-.10

.92

EDI

30.04(9.21)

30.32(7.00)

.14

.89

124.28(29.93)

124.12(32.00)

-.02

.99

30.04(9.21)

27.96(9.75)

-.78

.44

Negative ThoughtsDistress

184.88(87.58)

176.64(71.28)

-.37

.72

Negative ThoughtsBelievability

206.40(88.83)

210.44(77.83)

.17

.87

BIAAQ
DDS

DEFUSION, THIN IDEAL, BODY IMAGE

66

Table 3- Summary of Independent Sample T-tests for the PASTAS


Time
Post-intervention

Control
M(SD)
18.92(8.74)

Experimental
M(SD)
12.63(7.45)

t
-2.71

p
<.01**

Follow-up

18.48(11.14)

10.92(7.19)

-2.85

<.01**

DEFUSION, THIN IDEAL, BODY IMAGE

67

Table 4- Summary of Interaction Effects of Mixed Between-Within Analysis of Variance


Measure

PANAS(Negative)

2.85

.07

Partial Eta
Squared
.11

PANAS (Distress)

1.62

.21

.06

EDI

3.66

.03**

.14

BIAAQ

.19

.83

.008

DDS

1.76

.18

.07

Negative Thoughts (Distress)

1.07

.35

.04

Negative Thoughts (Believability)

1.91

.16

.08

DEFUSION, THIN IDEAL, BODY IMAGE


Appendix A: Copies of Measures

DEMOGRAPHICS QUESTIONNAIRE
1. Age: _______
2. Gender:
a) Male
b) Female
3. What race do you identify with? (can check multiple boxes):
a) White
b) Black/African-American
c) American Indian/Alaskan Native
d) Asian
e) Hawaiian Native/ Pacific Islander
f) Other
4. What is your ethnicity?
a) Hispanic/Latino(a)
b) Non- Hispanic/Latino(a)
5. Current height : ________
6. Current weight: ________

68

DEFUSION, THIN IDEAL, BODY IMAGE

69

DIETING AND WEIGHT HISTORY QUESTIONNAIRE (DWHQ)


Dieting and Weight History Questionnaire
1. What is the most you have ever weighed since reaching you current height (do not
count any weight gains due to medical conditions or medication)? The most I
have weighed since reaching my current height is: _______ pounds
2. What is the difference between this highest weight and your current weight?
_______ pounds
3. If your answer to number 2 is less than 10 lbs. skip this item and go on to item 4.
If your answer to number 2 is 10 lbs. or more, indicate which of the three
following statements describe you best:
a) The difference between my highest weight and my current weight exists
because I intentionally lost weight.
b) The difference between my highest weight and my current weight exists
because I lost weight even though I wasnt trying to.
c) I dont really know why I weight less than I once did.
4. Are you currently on a diet?
a) Yes
b) No (If no, go to number 6).
5. Are you currently dieting to lose weight or to avoid gaining weight?
a) To lose weight (go to # 7)
b) To avoid gaining weight (go to # 7)
6. Have you ever been on a diet to control your weight?
a) Yes
b) No (If no, go to # 7)
7. About how old were you when you went on your first diet? _____ years old
8. Please estimate as best you can the number of times in your life you have dieted
and lost the indicated amount of weight:
How many times have you dieted and lost:
____ 1-4 pounds
____ 5-10 pounds
____ 11-15 pounds
____ 16 or more pounds

DEFUSION, THIN IDEAL, BODY IMAGE


SOCIOCULTURAL ATTITUDES TOWARDS APPEARANCE
QUESTIONNAIRE (SATAQ-3)- INTERNALIZATION SUBSCALE
Please read each of the following items carefully and indicate the number that best
reflects your agreement with the statement.
Definitely Disagree= 1
Mostly Disagree= 2
Neither Agree Nor Disagree= 3
Mostly Agree = 4
Definitely Agree = 5
1.
2.
3.
4.
5.
6.

I do not care if my body looks like the body of people who are on TV. ______
I compare my body to the bodies of people who are on TV. ______
I would like my body to look like the models who appear in magazines. ______
I compare my appearance to the appearance of TV and movie stars. ______
I would like my body to look like the people who are in movies. ______
I do not compare my body to the bodies of people who appear in magazines.
______
7. I wish I looked like the models in music videos.______
8. I compare my appearance to the appearance of people in magazines. ______
9. I do not try to look like the people on TV. ______

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71

ROSENBERG SELF-ESTEEM SCALE


Rosenberg Self-Esteem Scale (Rosenberg, 1965)
Instructions: Below is a list of statements dealing with your general feelings about
yourself. If you strongly agree, circle SA. If you agree with the statement, circle A. If you
disagree, circle D. If you strongly disagree, circle SD.

1.
2.*
3.
4.
5.*
6.*
7.
8.*
9.*
10.

On the whole, I am satisfied with myself.


At times, I think I am no good at all.
I feel that I have a number of good qualities.
I am able to do things as well as most other people.
I feel I do not have much to be proud of.
I certainly feel useless at times.
I feel that Im a person of worth, at least on an equal plane
with
Iothers.
wish I could have more respect for myself.
All in all, I am inclined to feel that I am a failure.
I take a positive attitude toward myself.

SA
SA
SA
SA
SA
SA
SA

A
A
A
A
A
A
A

D
D
D
D
D
D
D

SD
SD
SD
SD
SD
SD
SD

SA A D
SA A D
SA A D

SD
SD
SD

Scoring: SA=3, A=2, D=1, SD=0. Items with an asterisk are reverse scored, that
is, SA=0, A=1, D=2, SD=3. Sum the scores for the 10 items. The higher the
score, the higher the self esteem.

DEFUSION, THIN IDEAL, BODY IMAGE


PHYSICAL APPEARANCE RELATED TEASING SCALE (PARTS)

72

DEFUSION, THIN IDEAL, BODY IMAGE

73

POSITIVE AND NEGATIVE AFFECT SCALE (PANAS)


PANAS Questionnaire
This scale consists of a number of words that describe different feelings and emotions.
Read each item and then list the number from the scale below next to each word.
Indicate to what extent you feel this way right now, that is, at the present
moment OR indicate the extent you have felt this way over the past week (circle
the instructions you followed when taking this measure)
1 = Very Slightly or Not at All
2 = A Little
3= Moderately
4= Quite a Bit
5= Extremely

1. Interested
2. Distressed
3. Excited
4. Upset
5. Strong
6. Guilty
7. Scared
8. Hostile
9. Enthusiastic
10. Proud
11. Irritable
12. Alert
__________ 13. Ashamed
14. Inspired
15. Nervous
16. Determined
17. Attentive
18. Jittery
__________ 19. Active
20. Afraid
Scoring Instructions:
Positive Affect Score: Add the scores on items 1, 3, 5, 9, 10, 12, 14, 16,

DEFUSION, THIN IDEAL, BODY IMAGE


17, and 19. Scores can range from 10 50, with higher scores represent- ing
higher levels of positive affect. Mean Scores: Momentary = 29.7 (SD = 7.9);
Weekly = 33.3 (SD = 7.2)
Negative Affect Score: Add the scores on items 2, 4, 6, 7, 8, 11, 13, 15,
18, and 20. Scores can range from 10 50, with lower scores representing lower
levels of negative affect. Mean Score: Momentary = 14.8 (SD = 5.4); Weekly
= 17.4 (SD = 6.2)

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DEFUSION, THIN IDEAL, BODY IMAGE

75

EATING DISORDERS INVENTORY 2 BODY DISSATISFACTION


SUBSCALE
EDI-2
The items ask about your attitudes, feelings, and behaviors. Some of the items relate to
food or eating. Other items ask about your feelings about yourself. For each item, decide
if the item is true about you ALWAYS ( A), USUALLY (U), OFTEN (O), SOMETIMES
(S), RARELY (R) , or NEVER (N). Respond to all of the items, making sure that you
circle the letter for the rating that is true about you.

1.
2.
3.
4.
5.
6.
7.
8.

I think that much stomach is too big.


I think that my thighs are too large.
I feel extremely guilty after overeating.
I feel satisfied with the shape of my body.
I like the shape of my buttocks.
I think my hips are too big.
I think that my thighs are just the right size.
I think my buttocks are too large.

DEFUSION, THIN IDEAL, BODY IMAGE

76

PHYSICAL APPEARANCE STATE AND TRAIT ANXIETY SCALE (PASTAS)


- STATE VERSION
The statements listed below are used to describe how anxious, tense, or nervous you feel
Right Now about your body. Use the following scale:
Not at All

Slightly

Moderately

Very Much So

Exceptionally So

Right now, I feel anxious, tense, or nervous about:


1.

The extent to which I look overweight.

2.

My thighs.

3.

My buttocks.

4.

My hips.

5.

My stomach (abdomen).

6.

My legs.

7.

My waist.

8.

My muscle tone.

9.

My ears.

10.

My lips.

11.

My wrists.

12.

My hands.

13.

My forehead.

14.

My neck.

15.

My chin.

16.

My feet.

DEFUSION, THIN IDEAL, BODY IMAGE

BI-AAQ
Directions: Below you will find a list of statements. Please rate the truth of each
statement as it applies to you. Use the following rating scale to make your choices. For
instance, if you believe a statement is Always True, you would write a 7 next to that
statement.
1-Never True
2-Very Seldom True
3-Seldom True
4-Sometimes True
5-Frequently True
6-Almost Always True
7-Always True
_____1. I get on with my life even when I feel bad about my body.
_____2. Worrying about my weight makes it difficult for me to live a life that I value.
_____3. I would gladly sacrifice important things in my life to be able to stop
worrying about my weight.
_____4. I care too much about my weight and body shape.
_____5. How I feel about my body has very little to do with the daily choices I make.
_____6. Many things are more important to me than feeling better about my weight.
_____7. There are many things I do to try and stop feeling bad about my body weight
and shape.
_____8. I worry about not being able to control bad feelings about my body.
_____9. I do not need to feel better about my body before doing things that are
important to me.
_____10. I dont do things that might make me feel fat.
_____11. I shut down when I feel bad about my body shape or weight.
_____12. My worries about my weight do not get in the way of my success.
_____13. I can move toward important goals, even when feeling bad about my body.
_____14. There are things I do to distract myself from thinking about my body shape
or size.
_____15. My thoughts and feelings about my body weight and shape must change
before I can take important steps in my life.
_____16. My thoughts about my body shape and weight do not interfere with the way
I want to live.
_____17. I cannot stand feeling fat.
_____18. Worrying about my body takes up too much of my time.
_____19. If I start to feel fat, I try to think about something else.
_____20. Worrying about my weight does not get in my way.
_____21. Before I can make any serious plans, I have to feel better about my body.
_____22. I will have better control over my life if I can control my negative thoughts
about my body.
_____23. I avoid putting myself in situations where I might feel bad about my body.
_____24. To control my life, I need to control my weight.
_____25. My worries and fears about my weight are true.

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DEFUSION, THIN IDEAL, BODY IMAGE


_____26. Feeling fat causes problems in my life.
_____27. I do things to control my weight so I can stop worrying about the way my
body looks.
_____28. When I start thinking about the size and shape of my body, its hard to do
anything else.
_____29. My relationships would be better if my body weight and/or shape did not
bother me.
Emily K. Sandoz, University of Mississippi.
Permission is hereby granted for reproduction of the BIAQ for clinical, empirical, or
personal use. Publication and/or sale of the BIAQ, however, is prohibited

78

DEFUSION, THIN IDEAL, BODY IMAGE

79

DREXEL DEFUSION SCALE (DDS)

Defusion is a term used by psychologists to describe a state of achieving distance


from internal experiences such as thoughts and feelings. Suppose you put your
hands over your face and someone asks you, What do hands look like? You
might answer, They are all dark. If you held your hands out a few inches away,
you might add, they have fingers and lines in them. In a similar way, getting
some distance from your thoughts allows you to see them for what they are. The
point is to notice the process of thinking as it happens rather than only noticing
the results of that process, in other words, your thoughts. When you think a
thought, it colors your world. When you see a thought from a distance, you can
still see how it colors your world (you understand what it means), but you also
see that you are doing the coloring. It would be as if you always wore yellow
sunglasses and forgot you were wearing them. Defusion is like taking off your
glasses and holding them several inches away from your face; then you can see
how they make the world appear to be yellow instead of only seeing the yellow
world.
Similarly, when you are defused from an emotion you can see yourself having the
emotion, rather than simply being in it. When you are defused from a craving or a
sensation of pain, you dont just experience the craving or pain, you see yourself
having them. Defusion allows you to see thoughts, feelings, cravings, and pain as
simply processes taking place in your brain. The more defused you are from
thoughts or feelings, the less automatically you act on them.
For example, you may do something embarrassing and have the thought Im
such an idiot. If you are able to defuse from this thought, you will be able to see
it as just a thought. In other words you can see that the thought is something in
your mind that may or may not be true. If you are not able to defuse, you would
take the thought as literally true, and your feelings and actions would
automatically be impacted by the thought.
Drexel Defusion Scale (DDS)

Very much
Quite a lot
Moderately
Somewhat
A little
Not at all

(0)
Based on the definition of defusion above, please rate each
(3) (4) (5)
(1) (2)
scenario according to the extent to which you would normally be
in a state of defusion in the specified situation. You may want to
read through all the examples before beginning to respond to the
questions. (Important: you are not being asked about the degree to
which you would think certain thoughts or feel a certain way, but the
degree to which you would defuse if you did.)
Feelings of Anger. You become angry when someone takes your
1 place in a long line. To what extent would you normally be able to
defuse from feelings of anger?
2 Cravings for Food. You see your favorite food and have the urge

DEFUSION, THIN IDEAL, BODY IMAGE


to eat it. To what extent would you normally be able to defuse from
cravings for food?
Physical Pain. Imagine that you bang your knee on a table leg. To
3 what extent would you normally be able to defuse from physical
pain?
Anxious Thoughts. Things have not been going well at school or
at your job, and work just keeps piling up. To what extent would
4
you normally be able to defuse from anxious thoughts like Ill
never get this done.?
Thoughts of self. Imagine you are having a thought such as no
5 one likes me. To what extent would you normally be able to
defuse from negative thoughts about yourself?
Thoughts of Hopelessness. You are feeling sad and stuck in a
difficult situation that has no obvious end in sight. You experience
6 thoughts such as Things will never get any better. To what extent
would you normally be able to defuse from thoughts of
hopelessness?
Thoughts about motivation or ability. Imagine you are having a
thought such as I cant do this or I just cant get started. To
7
what extent would you normally be able to defuse from thoughts
about motivation or ability?
Thoughts about Your Future. Imagine you are having thoughts
like, Ill never make it or I have no future. To what extent
8
would you normally be able to defuse from thoughts about your
future?
Sensations of Fear. You are about to give a presentation to a large
group. As you sit waiting your turn, you start to notice your heart
9 racing, butterflies in your stomach, and your hands trembling. To
what extent would you normally be able to defuse from sensations
of fear?
Feelings of Sadness. Imagine that you lose out on something you
1
really wanted. You have feelings of sadness. To what extent
0
would you normally be able to defuse from feelings of sadness?
Anxiety About Group Social Situations. You are preparing to go
to a party and experience thoughts such as "I won't make a good
1
impression" and "I won't be able to start and maintain
1
conversations." To what extent would you normally be able to
defuse from anxious thoughts about a group social situation?
Anxiety About One-on-One Interpersonal Situations. You find
yourself alone with a coworker or classmate whom you don't know
well. This person says hello, and looks as if he or she want to talk.
1
You experience thoughts such as "I won't have anything to say" and
2
symptoms of anxiety such as a racing heart and flushing. To what
extent would you normally be able to defuse from such anxious
thoughts and feelings in one-on-one interpersonal situations?

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DEFUSION, THIN IDEAL, BODY IMAGE

81

Appendix B: Outline of Cognitive Defusion Intervention

Cognitive Defusion Intervention


1. Introductions
o Name, age, why you decided to join the group
2. Body dissatisfaction
o Normative discontent
o Role of the media
o Psycho-educational/ Media literacy information show how pictures of models
are altered using Photoshop
3. Have you tried anything to get rid of your body image dissatisfaction?
o Link between thoughts, feelings, behaviors
o Common thoughts that may come up about dissatisfaction with your body
o What happens when you try not to think a particular thought? You think about it
more! (Yellow Jeep exercise)
4. A New Strategy: Introduction to Defusion
o distance from internal experiences
o defusion refers to the process of getting some distance from your thoughts and
feelings and being able to see yourself as separate from them
o Seeing your thoughts as just thoughts instead of absolute truth
5. What is the Opposite of Defusion?
o Fusion- your thoughts become a part of you
o Automatic behavior/action
6. Hands over face metaphor
o Hold your hand in front of your face. What do you see? Slowly, move your hand
away. What do you see now? (e.g., the lines and outline of the hand).
o Inside of thoughts versus distance from thoughts => seeing thoughts as thoughts
rather than as truth.
7. Deliteralization of language
o Your Mind is Not Your Friend Intervention chattering of your mind
o Milk exercise => although at first when you say the word milk, you imagine
the white, liquid substance. After repeating the word over and over it loses its
meaning and just becomes a sound.

DEFUSION, THIN IDEAL, BODY IMAGE

82

8. Evaluation vs. description


o Bad cup metaphor can find something wrong with anything if you choose to
evaluate it. Pick something in the room- how would you describe this object?
How would you evaluate it?
o Could you pick something about yourself (a certain aspect of your body that your
struggle with) that could be described vs. evaluated?
9. Cognitive defusion exercises:
o Im having the thought that
a.) I hate my body vs. Im having the thought that I hate my body
o Leaves on a stream
a.) being an outside observer and watching your internal experiences go by like
leaves on a stream
o Treating the mind as an external event
a.) you are greater than the sum of your thoughts- your mind is a separate entity
10. Conclusion