Mirror, Mirror, on the Wall

Whether it’s a quick glance before leaving the house or an hour-long effort to pull together the perfect outfit, looking in the mirror is something most people do on a daily basis. We also regularly see our images in shop window reflections, selfies, and social media feeds.

At face value, seeing our reflections might seem trivial; however, a growing number of body image and eating disorder researchers are learning that the experience of seeing our image can be quite difficult for some, impacting body dissatisfaction. Over the last decade plus, important studies about a treatment aiming to reduce body dissatisfaction, mirror exposure therapy, have been published.

Exposure therapy is a psychotherapy known to be highly effective in treating obsessive-compulsive disorder, anxiety disorders, and PTSD. In exposure therapy, therapists coach patients to lean into fears and discomfort – rather than avoiding these experiences – and to learn, through a series of in-session experiments and homework sessions, that they can manage these feelings. With repeated practice, the intensity of the distress may diminish or become easier to experience. At the Columbia Center for Eating Disorders, we have previously adapted this approach to eating- and food-related fears for patients with anorexia nervosa.

In mirror exposure therapy, over the course of multiple sessions, individuals practice looking at themselves in the mirror with guidance from a therapist. As in other forms of exposure therapy, the in-session practice involves working somewhat systematically up a hierarchy of challenges – in this case, by wearing increasingly difficult outfits.

The Locus of Your Focus

In order to understand how mirror exposure therapy works, it’s important to first understand where people direct their gaze when looking in the mirror. For individuals with no history of an eating disorder, gaze time appears to be split evenly between the features that they find most attractive about themselves and the features they find least attractive. However, people with anorexia nervosa and bulimia nervosa report spending significantly more time looking at the parts of their body that they find the most ugly or unattractive. These individuals also tend to either check themselves in the mirror quite frequently or avoid looking in the mirror altogether. Context matters too. For example, experiencing an uncomfortable emotion such as sadness or anger can increase the amount of time spent look at “unattractive” body parts.

The bottom line seems to be that looking at oneself too much, too intensely, or not at all can create problems and maintain body image distress. Mirror exposure therapy aims to reduce this distress by directly interrupting the problematic behavior while receiving support from a therapist.

What does mirror exposure therapy involve?

Mirror exposure therapy can be conducted in a few different ways and may also be incorporated into other types of treatment, such as cognitive behavioral therapy (CBT). Most commonly, the therapist will ask the individual to describe their reflection using non-judgmental language, progressing from their head all the way down to their feet. Descriptive, non-judgmental language includes describing features in terms of

• shape,
• texture, or
• color.

Participants are coached to use neutral or objective words and phrases. For example, “big ears” may become “semi-circles like half-moons on each side of my face, starting about halfway down, with a silver metal hoop earring falling half an inch from the bottom of the moon on each side.”

In other versions of mirror exposure therapy, patients may be asked to

• simply observe themselves in the mirror and comment on any emotions that arise,
• expand their posture, or
• describe their body using positive language, for example, describing the beauty of attractive body parts.

Sessions vary in length and can be conducted either individually or in a group. This is a time-limited approach, meaning that there tend to be a fixed number of sessions with the goal of helping the patient become their own therapist by the end. It’s recommended that the therapist be the same gender as the patient.

Does it work?

For people with bulimia nervosa and binge eating disorder, mirror exposure appears to be most effective when incorporated into CBT. Mirror exposure sessions during a course of CBT can help reduce body dissatisfaction, distress, and negative thoughts, and can also lead to improvement in binge-eating symptoms. Similarly, mirror exposure therapy appears to help decrease shape and weight concerns in people with anorexia nervosa who have completed weight restoration. For individuals with no history of an eating disorder who experience body dissatisfaction, this approach also helps decrease negative body-related thoughts and feelings of ugliness.

When might mirror exposure therapy NOT be the best fit?

Although guided mirror exposure is a promising intervention, it may not always be appropriate. When there is a recommendation for weight restoration, such as for people with acute anorexia nervosa or atypical anorexia nervosa, it is advisable to consider mirror exposure only after weight has improved and is securely stabilized. Otherwise, mirror exposure may run the risk of normalizing an underweight state or be counterproductive because the body is expected to change with renourishment. When patients are experiencing symptoms of depression or have current or past self-harm behaviors, an experienced mirror exposure therapist will carefully assess whether this approach is appropriate, or best to be re-evaluated in the future.

What do we need to learn next?

More research is needed to help us better understand how mirror exposure therapy stacks up against existing treatments and when it should or shouldn’t be used. Not only do we need larger samples, but it’s also important for groups who have not been adequately represented in the existing samples to be included, such as men, transgender individuals, and people of color. Because eating disorders do not discriminate, it would also be useful to know if or how mirror exposure therapy holds up across cultures.

For a closer look at the publication referenced in this post, read here:

Griffen, T.C., Naumann, E., & Hildebrandt, T. (2018). Mirror exposure therapy for body image disturbances and eating disorders: A review. Clinical Psychology Review, https://doi.org/10.1016/j.cpr.2018.08.006.

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