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Internet-delivered eating disorder prevention: a randomized controlled trial of dissonance-based and cognitive-behavioral treatments

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Internet-delivered eating disorder prevention: a randomized controlled trial of dissonance-based and cognitive-behavioral treatments

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Content Running Head: EATING DISORDER PREVENTION

Internet-delivered Eating Disorder Prevention: A Randomized Controlled Trial of
Dissonance-based and Cognitive-behavioral Treatments
BY
Taona Patricia Chithambo
__________________________________

A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirement for the Degree
DOCTOR OF PHILOSOPHY
(PSYCHOLOGY)

DEGREE CONFERRAL DATE:
August 6, 2016

University of Southern California
EATING DISORDER PREVENTION i
Acknowledgements

A special thank you to my research advisor and mentor, Dr. Stan Huey, who has shaped
my career in more ways than I can count. I am certainly a more astute scholar due to your
ongoing guidance throughout the years. I would also like to thank the members of my
dissertation committee, Drs. Steven Lopez, Margy Gatz, David Schwartz, Wendy Wood, and
Peggy McLaughlin, whose feedback was essential to the successful development and
implementation of this study.
I wish to thank my parents, Drs. Loyce and Godfrey Chithambo, who are the reason I was
able to pursue and complete my PhD. Thank you for encouraging me to keep going no matter
what, and for believing that I could overcome any obstacle that was thrown my way. I could not
have done this without you.
My younger sisters, Mayeso and Anji, and my little brother CG have patiently tolerated
kind of/sort of knowing what their big sister has been up to at school for the better part of a
decade. I’d like to thank them for their support, and wish them the best as they pursue their own
life endeavors.
I would also like to acknowledge my fellow Huey lab-mates, Jackie Tilley, Eddie Jones,
Marie Gillespie, and Gabby Lewine. I have enjoyed a rewarding friendship with my lab
colleague and officemate Caitlin Smith, who has been a source of support throughout my
graduate career.
Finally, I would like to say thank you to my dear Peter Haderlein, for showing up at just
the right time.
EATING DISORDER PREVENTION ii
Table of Contents

Acknowledgments i
Table of Contents ii
List of Tables iii
List of Figures iv
Abstract 1
Background and Significance 2
Method 11
Results 21
Discussion 28
References
Appendix A: Tables and Figures
38
49
Figure Captions 59
Appendix B: Study Outcomes for Follow-up Assessment Completers 73
Figure Captions (Follow-up Assessment Completers) 76
Appendix C: DBI-I Session Content 82
Appendix D: CBT-I Session Content 104
Appendix E: Author-developed Assessment Measures 128
EATING DISORDER PREVENTION iii
List of Tables
Table 1: Baseline Demographics and Clinical Characteristics of the Sample 49

Table 2: DBI-I vs. CBT-I Session Completion Summary 50

Table 3: DBI-I vs. CBT-I Homework Completion Summary 51

Table 4: Tests of Homework Completion as Predictor of Primary Study Outcomes 52

Table 5: DBI-I vs. CBT-I Comparison of Intra-session Outcome Measures 53

Table 6: Raw Means and Standard Deviations of Primary Outcome Variables at
Each Time Point

54
Table 7: Regression Results for Primary Study Outcomes 55

Table 8: Tests of Mediators of the Association Between Treatment Condition and
Composite Eating Pathology

56
Table 9: Tests of Mediators of the Association Between Treatment Condition and
Dieting

57
Table 10: Rates of Statistically Reliable Change by Condition 58
EATING DISORDER PREVENTION

iv
List of Figures

Figure 1: Hypothesized mediation model 60

Figure 2: Participant flow chart

61
Figure 3: Mean eating pathology by treatment condition

62
Figure 4: Mean body dissatisfaction by treatment condition

63
Figure 5: Mean thin-ideal internalization by treatment condition

64
Figure 6: Mean dieting by treatment condition

65
Figure 7: Mean depression by treatment condition

66
Figure 8: Mediation pathways for the association between treatment (CBT-I vs. DBI-I)
and composite eating pathology

67
Figure 9: Mediation pathways for the association between treatment (CBT-I vs. NT)
and composite eating pathology

68
Figure 10: Mediation pathways for the association between treatment (DBI-I vs. NT)
and composite eating pathology

69
Figure 11 Mediation pathways for the association between treatment (CBT-I vs. DBI-I)
and dieting

70
Figure 12 Mediation pathways for the association between treatment (CBT-I vs. NT)
and dieting

71
Figure 13 Mediation pathways for the association between treatment (DBI-I vs. NT)
and dieting
72
EATING DISORDER PREVENTION

1

Abstract

Objective: Individuals who exhibit maladaptive eating behaviors are unlikely to seek treatment
due to concerns regarding stigma and low insight into the severity of presenting symptoms.
Internet-based intervention strategies stand to increase the likelihood of treatment-seeking due to
enhanced privacy and convenience of access. The purpose of this study was to evaluate two web-
based programs for eating disorder prevention. Method: The current study (N=278) was a
randomized clinical trial comparing the efficacy of internet dissonance-based intervention
(DBI-I), internet cognitive-behavioral treatment (CBT-I) and no treatment (NT) in a high-risk
sample with elevated body image concerns. Thin-ideal internalization and body dissatisfaction
were evaluated as mediators of treatment effects. Results: At post-treatment, DBI-I and CBT-I
led to greater reductions in body dissatisfaction, depression, and thin-ideal internalization than
NT. CBT-I was more effective at reducing dieting than DBI-I, and a trend favoring CBT-I over
DBI-I was detected for body dissatisfaction. Although body dissatisfaction emerged as a
mediator of select treatment effects, mediation analyses for thin-ideal internalization were non-
significant. Conclusions: Internet intervention is an effective mode of delivery for eating
disorder prevention. While no evidence of theory-specific mechanisms was found, body
dissatisfaction was identified as a mediator of treatment outcomes. Potential directions for future
research include adaptation of the interventions to a mobile format and the addition of
interpersonal elements (e.g., therapist guidance) to the treatment protocol.

Keywords: dissonance-based intervention, cognitive-behavioral therapy, internet, mediators,
eating disorder prevention, randomized controlled trial

EATING DISORDER PREVENTION

2
Background and Significance
Efficacy of Eating Disorder Prevention
Eating disorders (EDs) are among the most severe and debilitating mental health
syndromes. Due to pronounced physiological damage caused by controlled eating, EDs are
associated with increased mortality risk (Smink, Hoeken, & Hoek, 2012). As medical
intervention is a central component in the rehabilitation of ED, national expenditures for hospital
procedures involving EDs are approximately $271 million per year (Zhao & Encinosa, 2009).
Moreover, individuals with EDs are at elevated risk for the development of other psychiatric
problems, including depression and suicidal behavior (Hudson, Hiripi, & Kessler, 2007; Johnson,
Cohen, Kasen, & Brook, 2002). In response to the substantial social, psychological, and
economic costs attributed to EDs, various behavioral interventions have been implemented
toward the goal of ED prevention.
ED prevention programs aim to either prevent the development of ED symptoms among
healthy individuals (primary prevention) or reduce existing symptoms among individuals at risk
(secondary prevention; Austin, 2000). Meta-analytic studies report that secondary ED prevention
programs yield superior post-intervention effects when compared to primary prevention for the
reduction of negative affect, eating pathology, and dieting (Fingeret, Warren, Cepeda-Benito, &
Gleaves, 2006; Stice & Shaw, 2004). Investigators have also examined whether treatment
orientation might influence ED prevention outcomes (Fingeret et al., 2006; Stice, Shaw, & Marti,
2007). To date, the two treatments that have been applied most frequently in the field of ED
prevention are cognitive-behavioral treatment (CBT) and dissonance-based intervention (DBI).
Cognitive-behavioral ED prevention. CBT for ED is based on the premise that
psychological risk factors (e.g., fear of fatness, concern with body size/shape) increase an
EATING DISORDER PREVENTION

3
individual’s vulnerability to negative self-schemas involving body image and eating
(Williamson, White, York-Crowe, & Stewart, 2004). As a result, sensitivity to internal and
external cues related to eating and physical appearance becomes heightened, reinforcing
cognitive biases regarding the consequences of eating and weight gain. Maladaptive eating
behaviors, such as dieting, binge eating, and purging, are utilized by individuals with ED to
reduce the negative affect associated with unpleasant cognitions. These behaviors serve as
negative reinforcement by temporarily alleviating emotional discomfort, sustaining a cycle of
maladaptive thoughts, emotions, and eating habits (Williamson et al., 2004). Accordingly, CBT
focuses on the modification of distorted cognitions related to body shape and weight (Wilson,
Fairburn, & Agras, 1997). The patient is made aware of the associations between her thoughts,
emotions, and eating behaviors, so that they can be targeted for restructuring.
Though many studies report positive treatment effects for CBT in the context of
interventions for threshold EDs (Murphy, Straebler, Cooper, & Fairburn, 2010), support for CBT
for ED prevention in the traditional face-to-face format is weak. For example, Nicolino, Martz,
and Curin (2001) reported that a single-session group CBT prevention program did not produce
significant effects for any of the hypothesized outcome variables (body image, fear of fat,
anxiety concerning physical appearance, dieting) at post-treatment or 1-month follow-up. A
meta-analysis by Fingeret et al. (2006) examined treatment format (CBT/psychoeducation vs.
pure psychoeducation) as a moderator of ED prevention outcomes; post-treatment moderation
effects for dieting, thin-ideal internalization, and body dissatisfaction were non-significant,
suggesting that CBT did not enhance treatment effects relative to psychoeducation. The use of
face-to-face CBT for ED prevention has declined in recent years; indeed, the most recent
published trial evaluating CBT-based ED prevention in a traditional platform took place in 2001
EATING DISORDER PREVENTION

4
(Nicolino, Martz, & Curin, 2001). This can likely be attributed to mounting evidence for the
efficacy of DBI for ED prevention.
Dissonance-based ED prevention. DBI is a well-validated treatment paradigm for the
prevention of EDs (Stice, Shaw, & Marti, 2007). DBIs address thin-ideal internalization by
encouraging participants with body image concerns to actively argue against the media-
propagated thin ideal body type (Stice et al., 2007; Stice, Mazotti, Weibel, & Agras, 2000). DBIs
are informed by cognitive-dissonance theory, which posits that discrepancy between beliefs and
behaviors fosters psychological discomfort (Festinger, 1957). This discomfort engenders
motivation to change one’s attitudes, beliefs, or behaviors in accordance with a single viewpoint.
The authors of the Body Project, the first dissonance-based intervention for the prevention of
EDs (Stice & Presnell, 2007), apply cognitive dissonance theory by emphasizing that all
arguments against the thin-ideal should be generated by intervention participants, not treatment
facilitators. It is hypothesized that when participants with body image concerns engage in
activities that argue against the thin ideal, their beliefs and attitudes shift towards a less negative
body image to reduce cognitive dissonance. This shift in beliefs and attitudes is associated with
reduced body dissatisfaction and less restrictive eating (Stice, Rohde, Gau, & Shaw, 2009).
Research provides support for the efficacy of DBI, a strategy shown to reduce eating
pathology in multiple trials by independent investigators (Stice, Shaw, Becker, & Rohde, 2008).
Furthermore, meta-analytic work suggests that DBI is more efficacious than programs with
alternative treatment paradigms (e.g., healthy weight control, mindfulness; Stice et al., 2008).
Overall, it can be concluded that DBI for ED prevention has received substantial empirical
support.

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Theoretical Considerations
Though positive treatment outcomes have been identified for both DBI and CBT, no
research to date directly compares outcomes for these distinct intervention strategies. Moreover,
few ED prevention trials include head-to-head comparisons of active treatments. Indeed, 75% of
studies included in a 2014 meta-analysis of electronic ED prevention programs compared an
active treatment with a no-treatment or placebo control group (Loucas et al., 2014). Due to the
widespread implementation of the treatment vs. placebo/control study design in the ED literature,
little is known about the relative efficacy of different ED intervention strategies. To address this
issue, the current study compared the efficacy of internet-based DBI (DBI-I) and CBT (CBT-I)
for the prevention of EDs.
Kazdin (2007) recommended that experimental investigations adopt a design that allows
the researcher to identify specific mechanisms that account for predicted outcomes. In the
context of treatment evaluation research, such a design would compare the efficacy of therapies
that differ only with regard to the elements specific to their theoretical perspectives. Other
features, such as the structure and duration of treatment, the appearance of therapy materials
distributed to patients, and the nature of participant-provider interactions should be held constant
across conditions whenever possible. In the current study, DBI-I and CBT-I were designed to be
parallel in duration, appearance, and structure to increase the likelihood that differences in
outcome could be attributed to mechanisms specific to each treatment.
Regardless of treatment paradigm, factors posited to yield positive treatment effects
include a multiple-session (vs. single-session) design, an interactive (vs. didactic) treatment
format, and targeted (vs. universal) treatment delivery (Stice & Shaw, 2004). Both interventions
adopt all of these features. Another commonality is that both target the reduction of body image
EATING DISORDER PREVENTION

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disturbance, a risk factor for the onset of EDs (Ghaderi, 2001; Stice & Shaw, 2002). However,
DBI adopts an extrinsically focused, sociocultural perspective, while CBT places more emphasis
on the role of cognitive factors in sustaining poor body image. Based on these differences, it
stands to reason that DBI-I would be more efficacious in reducing culturally acquired attitudes
regarding ideal body shape, while CBT-I should be more effective in reducing maladaptive body
image cognitions.
A primary goal of the study was to evaluate the efficacy of internet-delivered ED
prevention. I hypothesized that DBI-I and CBT-I would lead to greater reductions in ED risk
factors than NT. I also expected that DBI-I and CBT-I would diverge in treatment outcomes, due
to the application of disparate mechanisms of change. Specifically, I hypothesized that CBT-I
would lead to lower post-treatment body dissatisfaction than DBI-I, and that DBI-I would lead to
lower post-treatment thin-ideal internalization than CBT-I. In addition to being the first
randomized controlled trial to attempt to distill mechanisms accounting for differences in CBT-I
and DBI-I, this is the first investigation to utilize internet-based intervention towards this goal.
Electronic ED Intervention
Despite the noted severity of eating problems, few individuals with ED symptoms seek
treatment for disturbed eating patterns (Cachelin & Striegel-Moore, 2006). Individuals with EDs
report considerable shame and guilt, contributing to a low likelihood of treatment-seeking
(Cachelin, Rebeck, Veisel, & Striegel-Moore, 2001). Furthermore, people with ED exhibit
limited insight regarding the severity of their symptoms; in a study by Cachelin and colleagues
(2001), only 5.7% of individuals diagnosed in a structured clinical interview reported that they
believed they had an ED. Among those who do seek treatment, less than 20% are expected to
pursue the counsel of a mental health professional, with the majority of individuals seeking
EATING DISORDER PREVENTION

7
advice from sources lacking ED expertise (e.g., general practitioner, informal social support
network; Cachelin et al., 2001). Given these challenges to the provision of face-to-face ED
intervention, electronic interventions are well suited to increase the likelihood of ED
treatment-seeking due to enhanced privacy and convenience of access.
In addition to reducing barriers to therapy access, electronic interventions offer
technology-driven advantages for the implementation of ED prevention. For example,
intervention components can be automated to ensure that participants receive a similar dosage of
active treatment ingredients (e.g., automatic release of therapy modules, pre-scheduled between-
session emails). Computerized programs are easier to standardize than face-to-face interventions,
increasing the likelihood that each participant will receive an equivalent version of the
intervention (Bauer & Moessner, 2013). Meta-analytic work suggests that internet-supported
treatments are comparable in efficacy to face-to-face treatments (Barak, Hen, Boniel-Nissim, &
Shapira, 2008), providing further support for the utilization of electronic intervention strategies.
Several reviews have been published in recent years with the aim of examining the
aggregate effects of electronic ED intervention. Two systematic reviews reported effect sizes for
individual studies (Aardoom et al., 2013; Dölemeyer et al., 2013). Aardoom and colleagues
(2013) included trials with diverse study designs (e.g., uncontrolled trials, controlled trials, case
series) whereas Dölemeyer et al. (2013) focused exclusively on controlled trials. Both research
groups reported results favoring internet-based intervention over waitlist control in the reduction
of eating pathology. In another recent review, Loucas et al. (2014) conducted a meta-analysis
that combined effect sizes from twenty electronic ED intervention studies. However, out of the
fifty effect sizes reported in the treatment meta-analysis (24 post-treatment, 26 follow-up), 96%
(n = 48) were derived from either one (n=36) or two (n=12) studies. A key advantage of meta-
EATING DISORDER PREVENTION

8
analysis is its increased statistical power when compared to examining single effect sizes
(Borenstein, Hedges, Higgins, & Rothstein, 2009). Because the majority of effect sizes reported
by Loucas et al. (2014) were derived from one study, their results may not accurately convey the
pooled effects for electronic ED intervention.
Chithambo and Huey (2015) addressed this limitation in a meta-analysis of ED
intervention outcomes for threshold symptomatology. The omnibus effect size for the meta-
analysis indicated that post-treatment effects were significantly higher for electronic intervention
compared with waitlist control. When outcomes were examined separately, moderate effects
were found favoring electronic intervention for bulimia symptoms, bingeing, and dietary
restraint, whereas a small effect size was found for body dissatisfaction. This trend contrasts with
findings for ED prevention programs, where effects tend to be smaller for clinical eating
pathology and larger for psychological risk factors (Beintner et al., 2012; Stice et al., 2007).
Nonetheless, the results provide support for the use of electronic intervention for ED
populations.
As the application of electronic ED intervention continues to increase in frequency, it is
important to identify specific factors that contribute to positive outcomes. Treatment orientation
is an important characteristic that may influence the efficacy of electronic ED intervention.
Because DBI and CBT are the most well-validated strategies in the face-to-face outcome
literature, one of my study objectives was to examine the efficacy of these interventions in an
electronic treatment context.
Efficacy of CBT electronic ED prevention. Though some evidence supports the overall
efficacy of CBT ED prevention (Portnoy et al., 2008), only a handful of protocols have been
subject to evaluation in multiple research trials. For example, Student Bodies, a CBT CD-ROM
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9
intervention later adapted for internet administration, is the most rigorously tested electronic
intervention to address eating pathology to date. The intervention takes place over the course of
eight weeks and includes a moderated online discussion board (Winzelberg et al., 1998). A meta-
analysis of Student Bodies outcomes reported moderate effects of the program on drive for
thinness, weight control, and knowledge, with small effects obtained for bulimia symptoms,
dietary restraint, and body dissatisfaction (Beintner, Jacobi, & Taylor, 2012). Therefore, the
program appears to be moderately effective in reducing attitudes related to the pursuit of weight
loss, whereas effects on eating behavior are small. Another CBT program, Set Your Body Free,
has also been subject to multiple empirical investigations (Paxton, 1993; Paxton, 1996; Paxton,
McLean, Gollings, Faulkner, & Wertheim, 2007). The intervention combines CBT and
educational components. In one study, the authors compared a face-to-face version of the
program to a computerized version of the same protocol (Paxton et al., 2007). They found that
while both treatments were superior to waitlist control at post-treatment, the face-to-face
treatment was more efficacious than the internet version. At 6-month follow-up, however,
outcomes did not differ between the active interventions, though both treatments remained
superior to waitlist control. Thus, although few CBT protocols have been implemented for
electronic ED prevention, extant research supports the efficacy of the treatment strategy for the
reduction of ED-related attitudes and cognitions.
Efficacy of dissonance-based electronic ED prevention. Only one known electronic
DBI protocol has been evaluated to date. Stice and colleagues (2012) compared the efficacy of
eBody Project, an online DBI program with 1) the original face-to-face protocol, Body Project,
2) a psychoeducational video condition, and 3) an educational brochure. Both eBody Project and
Body Project included activities that encouraged participants to verbally challenge the thin ideal
EATING DISORDER PREVENTION

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and engage in body activism-oriented homework exercises. Participants of the Body Project
exchanged verbal challenges in a group format, while eBody Project participants posted their
activities on an online discussion board. Body Project and eBody Project effects for thin-ideal
internalization, body dissatisfaction, negative affect, and ED symptoms did not differ
significantly. Also, with the exception of ED symptoms, post-treatment outcomes consistently
favored both versions of the DBI treatments over the control conditions. These results provide
evidence that face-to-face and internet DBI are comparable in effectiveness.
Mechanisms of Treatment Effects
Body dissatisfaction. In order to fully understand intervention effects for ED prevention,
it is important to identify potential treatment mechanisms. Towards this end, I evaluated body
dissatisfaction as a mediator of the effect of condition (DBI-I vs. CBT-I) on eating behaviors.
Specifically, where outcomes favoring CBT-I occurred, I predicted that the effect would be
mediated by change in body dissatisfaction. Such an outcome would be congruent with the
former program’s focus on modifying negative body cognitions to reduce the risk of ED onset. A
randomized controlled trial of CBT for threshold binge eating disorder reported weight and
shape concerns as mediators of change in binge abstinence (Dingemans, Spinhoven, & van
Furth, 2007), providing evidence for body dissatisfaction as a mechanism of CBT outcomes. To
support the CBT model, the magnitude of the mediation effect should exceed that of thin-ideal
internalization, the second mediator under investigation.
Thin-ideal internalization. In order to test a mechanism of change specific to the
theoretical tenets of DBI, thin-ideal internalization was also evaluated as a mediating variable.
Thin-ideal internalization, defined as the extent to which an individual endorses societally-
reinforced preferences for a slender body type, has been identified as a key risk factor for the
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development of EDs (Stice, 2002). It is theorized that thin-ideal internalization reflects a process
of social reinforcement, as the influence of peers, media, and respected others serves to promote
and encourage a slender body type (Thompson & Stice, 2001). Past research has identified thin-
ideal internalization as a mediator of DBI treatment effects. Using data from a DBI trial with 306
female high school students, Stice and colleagues found that change in thin-ideal internalization
predicted change in body dissatisfaction and eating symptoms (Stice, Marti, Rohde, & Shaw,
2011). Furthermore, change in thin-ideal internalization fully mediated the effects of intervention
condition (DBI vs. educational brochure control) on symptom reductions. In the current study,
thin-ideal internalization was also evaluated as a mediator of the association between treatment
condition (DBI-I vs. CBT-I) and eating behaviors. If the DBI theoretical model is correct, the
mediation effect for thin-ideal internalization should be greater in magnitude than that of body
dissatisfaction.
Additional mediation analyses were conducted to evaluate whether body dissatisfaction
and/or thin-ideal internalization mediated the effect of the active treatment conditions when
compared to NT. I expected for body dissatisfaction to mediate CBT-I effects, and for thin-ideal
internalization to mediate DBI-I effects.
Method
Participants
All participants were students at the University of Southern California (USC). Because
eating pathology is rare among males (Hudson, Hiripi, Pope, & Kessler, 2007), and because
intervention content focused on female body weight and shape, only women were included. As
preoccupation with body shape and weight is a diagnostic criterion for anorexia nervosa and
bulimia nervosa (American Psychiatric Association, 2013), the Weight Concerns Scale was used
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to assess symptom severity (WCS; Killen et al., 1994). Participants with a score of 34 (the mean
score for a community sample of adolescent females; Killen et al., 1996) or higher were eligible
for inclusion in the study. The WCS has adequate predictive validity for ED onset (Killen et al.,
1996), and has been utilized as a screening measure in previous electronic ED prevention
programs (Ljotsson et al., 2007; Manwaring et al., 2008; Barr Taylor et al., 2006).
As both active interventions are preventive in nature, individuals who exhibited severe
eating pathology, as indicated by a score of 20 or higher on the Eating Attitudes Test (Garner,
Olmstead, Bohr, & Garfinkel, 1982), were excluded from the study. Participants who endorsed a
2 (“I would like to kill myself”) or 3 (“I would kill myself if I had the chance”) on the Beck
Depression Inventory‘s suicidal thoughts or wishes item were ineligible as well (Beck, Steer, &
Brown, 1996). Participants excluded due to the presence of ED pathology or suicidal ideation
were provided with referral information to Los Angeles area treatment providers. In addition to
providing referral information online, I called participants who expressed suicidal ideation (n=1)
in order to assess risk and assure safety.
Procedures
Screening and recruitment. Participants were recruited from the USC student
population through the psychology subject pool. Individuals who signed up for the study were
emailed an internet link to a brief survey that included screening items to assess ED pathology
and suicidal ideation. Those deemed eligible were emailed instructions for logging into the
online interface, as well as a link to the study URL. The link directed participants to an
information sheet for consent and baseline assessment measures. A copy of the information sheet
was also provided via email. At the conclusion of the baseline assessment, a link to the first
treatment session was emailed to participants assigned to an active study condition. For the
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subsequent three sessions, an email containing an access link was sent on a weekly basis.
Excluding the assessment battery, the sessions and corresponding homework assignments were
designed to require approximately 1 hour a week of participants’ time. A maximum of 5 research
credits were administered upon completion of the post-treatment assessment. All study
procedures were approved by the University of Southern California Institutional Review Board.
Design. The study adopted a 3 (Treatment condition: DBI-I, CBT-I, NT) X 2 (Time: pre-
treatment, post-treatment) design, with participants randomized to DBI-I, CBT-I, or NT. In total,
278 individuals were recruited, exceeding the number required to detect a moderate effect size at
the p <.05 level (n = 168; GPower Statistical Software package, Faul, Erdfelder, Lang, &
Buchner, 2007). For all study conditions, outcome measures were collected on two occasions.
Time 1 data collection took place immediately prior to the first treatment session (Baseline; T1).
Time 2 data collection occurred four weeks later, following the fourth and final treatment session
(Post-treatment; T2). Participants in the control condition were assessed on the same schedule,
with T2 scheduled four weeks after T1. Thus, completion of all study activities required
approximately four weeks.
Although I attempted to collect one-month follow-up data (T3), only 41% of participants
(n=114) completed the follow-up assessment. Because coefficients estimated using a restricted
portion of the sample are less reliable (Enders & Bandalos, 2001), these data are not well-suited
to modern missing data strategies, such as full-information maximum likelihood estimation.
Therefore, I chose to focus on post-treatment outcomes for the current study. Results for T3
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completers can be found in Appendix B.
1

Intervention Conditions
DBI-I. The DBI-I program consisted of four sessions that took place over the course of
28 days at a frequency of one session per week. A homework assignment was given each week,
and was due one week after the preceding session. Each DBI-I session consisted of activities that
encouraged participants to write arguments against the thin-ideal. Content was derived primarily
from the facilitator manual for the latest version of the Body Project, an established DBI-I
protocol for ED prevention (Stice & Presnell, 2007). Prior to the launch of the study, two of the
developers of the Body Project reviewed the DBI-I program and provided feedback on
intervention content (E. Stice & P. Rohde, personal communication, November 26-December 6,
2012). In response to their comments, a “hint” feature was added to sessions eliciting verbal
feedback to prevent participants from becoming stuck on a prompt. During the first session,
participants typed written responses to prompts that provided education about the media-
propagated thin-ideal, and generated arguments against the thin ideal. For homework,
participants were assigned to write a letter to an adolescent girl detailing the costs of the thin-
ideal. For session 2, participants typed verbal challenges to statements that endorsed a drive
towards thinness (e.g., “I am too chubby to eat dessert after dinner today”). For the second
homework assignment, participants were assigned to come up with examples of thin-ideal
situations in their own lives, and write examples of how they would respond now given their
knowledge about the thin ideal. In session 3, participants typed examples of comebacks to verbal

1
There are several possible explanations for the substantial loss of participants from T2 to T3. Because 5 credits
were awarded upon completion of the T2 assessment, it is possible that the additional .5 credits offered for
completing T3 were a relatively small incentive. Also, several courses limit the number of online credits a student
can obtain to 5. Therefore, some students may not have completed the T3 survey because the additional credits for
the assessment could not be used towards their course requirements. Finally, some participants received the T3
questionnaire after the end of the semester. Although these participants had the option of receiving $10
compensation, the exclusion of course credit as a payment option may have reduced the likelihood of completing the
assessment.
EATING DISORDER PREVENTION

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statements that endorse the thin ideal. Participants were asked to generate 10 ways they could
publicly challenge the thin ideal as homework. During session 4, participants read information
on identifying instances of thin-ideal talk in their own lives. They also typed verbal challenges to
statements indicative of thin-ideal talk. For homework, participants were assigned to write a
second letter to an adolescent girl, taking into account the information they had learned
throughout the program. A full script for the DBI-I intervention, including homework
worksheets, is provided in Appendix C.
CBT-I. CBT-I also consisted of four sessions that occurred over a span of 28 days, with
sessions taking place at a frequency of once per week. The CBT-I sessions were designed to be
parallel in structure and appearance to DBI-I, but were based on an alternative theoretical model
positing that negative body image thoughts and assumptions sustain disturbed body evaluation
and maladaptive eating behaviors. Consequently, participants in this condition were instructed to
challenge appearance assumptions, as well as identify and restructure thoughts associated with
poor body image. During the first session, participants typed answers to questions that assessed
their knowledge of the symptoms and prevalence of poor body image. They were also
encouraged to reflect on the association between critical body image thoughts and low mood. For
homework, they were assigned to write a one-page summary of what they had learned in the
session. In session 2, participants identified alternative interpretations of cognitive distortions
that sustain poor body image. For homework, they were assigned to generate examples of
“appearance assumptions” relevant to their own lives and identify alternative interpretations.
During session 3, participants provided rational responses to hypothetical negative body
cognitions (e.g., “I am less attractive than everyone else”). As homework, participants were
assigned to generate a list of 10 benefits they might derive from changing their body image
EATING DISORDER PREVENTION

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thoughts. For session 4, participants typed responses challenging hypothetical insensitive body
remarks made by others. The participants were asked to write a one-page letter summarizing
what they had learned during the course of the intervention as a final homework assignment.
CBT-I content was derived from sections of The Body Image Workbook, a self-help manual for
body dissatisfaction (Cash, 1997). While this was the first web-based adaptation of the program,
controlled trials have reported efficacy of the original manual in reducing body dysphoria and
increasing appearance satisfaction (Strachan & Cash, 2002; Nye & Cash, 2006). Session content
and homework assignments for CBT-I are detailed in Appendix D.
NT. NT participants did not engage in any intervention activities; rather, their
participation consisted solely of completing the T1 and T2 assessment measures. Both active
treatments were housed online using Qualtrics, a program for administering internet
questionnaire data. Each participant used her USC email address and student ID number to log in
to all study activities.
Measures
Demographics. A demographics questionnaire developed for the study was used to
obtain information regarding participant age, gender, body mass, academic status, and self-
identified racial/ethnic background.
Body dissatisfaction. The 34-item Body Shape Questionnaire (BSQ; Cooper, Taylor,
Cooper, & Fairburn, 1987) assessed participants’ weight and shape concerns. Sample items
include “[h]ave you worried about your flesh not being firm enough?” and “[h]as eating even a
small amount of food made you feel fat?”. Responses indicate the frequency of weight-related
emotions and cognitions on a six-point Likert-type scale, ranging from 1 = “never” to 6 =
“always”. Validation studies report adequate test-retest reliability (r = .88), as well as concurrent
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validity with alternate measures of body image concern (Rosen, Jones, Ramirez, & Waxman,
1996). Coefficient alpha at baseline for the current study was .96.
Composite eating pathology. The Eating Attitudes Test (EAT) was used to measure
respondents’ clinical eating and body image pathology. For example, participants were asked to
indicate how often they “[have] the impulse to vomit after meals” or have “gone on eating
binges”. The dieting, bulimia, and restrictive eating subscales of the EAT correlated with bulimia
and body image dissatisfaction symptoms in prior studies (Garner et al., 1982). The reliability
coefficient was .81.
Dieting. The Dutch Restrained Eating Scale (DRES) assessed dieting behaviors, such as
how often respondents “[d]eliberately eat foods that are slimming” and “[d]eliberately eat less in
order to not become heavier” (Van Strien, Frijters, Van Staveren, Defares, & Deurenberg, 1986).
The DRES demonstrates high internal consistency (α = .95), as well as predictive validity for
bulimia symptom onset (Stice, Cooper, Schoeller, Tappe, & Lowe, 2007). Coefficient alpha was
.88.
Thin-ideal internalization. The revised Ideal Body Stereotype Scale (IBSS; Stice,
Ziemba, Margolis, & Flick, 1996) measured idealization of a slim female physique. The 8-item
scale assesses agreement with statements such as “slender women are more attractive” and
“women with toned (lean) bodies are more attractive” on a five-point scale, with 1 indicating
strong disagreement and 5 indicating strong agreement. The IBSS demonstrates adequate internal
reliability (α = .91), 2-week test-retest reliability (r=.80), and predictive validity for bulimia
symptom onset (Stice et al., 1996). For the current study, an alpha of .73 was obtained.
Depressive symptoms. The Beck Depression Inventory-II (BDI-II; Beck et al., 1996)
was used as a measure of depressive symptoms. The scale consists of 21 items that assess
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symptoms of depression experienced during the past week. The items are ordered on a four-point
scale, with higher points indicating increasing symptom severity. Domains assessed include
sadness, pessimism, and self-criticism. The BDI-II exhibits adequate internal consistency (α=.84;
Yin & Fan, 2000), as well as concurrent validity with alternate self-report measures of
depression (Storch, Roberti, & Roth, 2004). Coefficient alpha for the study sample was .90.
Treatment engagement. Treatment engagement was evaluated by examining the number
of completed sessions and completed homework assignments in each of the active treatment
conditions. Both session completion and homework completion have been used as measures of
treatment engagement in previous research (e.g., Carrard et al., 2011; Prinz & Miller, 1994;
Staudt, 2007).
Intra-session process measures. At the end of each session, DBI-I and CBT-I
participants completed scales assessing thin-deal internalization and negative body cognitions, as
well as a measure that served as a proxy for cognitive dissonance. Thin-ideal internalization was
measured with the IBSS, which was described earlier. Negative body cognitions were assessed
using the Body Thoughts Questionnaire (BTQ), which consisted of 10 statements including “I
can’t stand my appearance” and “My body has good proportions”; items reflecting positive
cognitions were reversed so that higher scores were associated with more negative body
thoughts. I developed the measure based on self-assessments featured in The Body Image
Workbook (Cash, 1997). The reliability coefficient following session 1 was .89.
Festinger (1962) posited that cognitive dissonance is a state of psychological discomfort
attributed to inconsistent cognitions and/or beliefs. Accordingly, the Dissonance Proxy Scale,
which I adapted from a scale by Sweeney and Hausknecht (2000), asked participants to report
their levels of negative affect (in order to measure of psychological discomfort) and ambivalence
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towards the information presented during the session (in order to measure cognitive
inconsistency). Examples of affect related questions include “I feel frustrated” and “I feel
annoyed”. Cognitively-oriented questions include “I wonder if I should try to change my body at
all” and “I wonder if I have been given false information”. Coefficient alpha following session 1
was .94. Full versions of the BTQ and Dissonance Proxy Scale are provided in Appendix E.
Analyses
Main outcomes. To evaluate the effect of treatment condition on the primary study
outcomes, I regressed each dependent variable on two dummy-coded vectors representing
treatment condition, with baseline scores for each respective outcome included as covariates in
the model. The first predictor was coded 0=NT and 1=DBI-I, and the second predictor was coded
0=NT and 1=CBT-I, so that the NT condition was designated as the reference group. Because
only two contrasts could be evaluated in a single model, for each outcome a second model was
run with DBI-I coded as the reference group to obtain a parameter estimate for the DBI-I vs.
CBT-I treatment effect. Wald χ
2
tests of the joint significance of coefficients were conducted to
determine whether the omnibus condition effect was significant (Tu & Zhou, 1999).
Mediation analyses. Preacher, Rucker, and Hayes (2007) have recommended
bootstrapping for mediation analysis, as the procedure adopts no assumptions regarding the
shape of the sampling distribution. In bootstrapping mediation analyses, a sampling distribution
of the indirect effect is estimated by calculating the indirect effect ab in randomly generated
subsamples of the original dataset (Preacher et al., 2007). For each resample, an indirect effect
a
+
b
+
is computed, a quantity derived from the resampled dataset rather than the original sample
(Preacher et al., 2007). This process is repeated K times, with K conventionally ranging between
1000 and 5000. To test for the significance of the mediation effect, the a
+
b
+
s are sorted from
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lowest to highest, and upper and lower bounds of a 100(1- )% confidence interval are
established using the ( /2)kth and (1+(1- /2))kth values in the sorted distribution (Preacher et
al., 2007). Because no symmetry assumption is made when using bootstrapping analyses, these
confidence intervals can be asymmetric. The null hypothesis of no indirect effect is rejected if 0
lies outside of the confidence interval (Preacher et al., 2007). Mediation hypotheses were
evaluated using the MODEL INDIRECT procedure in MPLUS, which estimates confidence
intervals surrounding the indirect effect ab using the bootstrapping method.
A multiple mediation approach was employed, where thin-ideal internalization and body
dissatisfaction were entered into the model as mediators simultaneously. See Figure 1 for a
conceptual representation of the hypothesized mediation model. In addition to reducing the
parameter bias that occurs when mediators are examined in separate models, this approach
facilitated examination of the relative magnitudes of the mediating effects (Preacher & Hayes,
2008). This analysis strategy was therefore well suited to the study’s aim of identifying
differences between the mediation effects of thin-ideal internalization and body dissatisfaction.
Missing data. Chi-square analyses were conducted to examine condition differences in
categorical outcomes, and t-tests were performed to examine whether differences occurred for
continuous variables. Full information maximum likelihood estimation was used to handle
missing data; the algorithm generates parameter estimates by using data from all observations,
rather than deleting cases with missing observations listwise (Enders & Bandalos, 2001).
In order to adhere to the maximum likelihood estimation assumption that data are missing
at random, a dummy variable denoting missingness from the T2 assessment (0 = no dropout, 1 =
dropout) was included in all regression models as a covariate. Because all
subject-level predictors of dropout may not be known, this is a more flexible approach to
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obtaining unbiased parameter estimates than the use of selection models that include predictors
of dropout (e.g., demographic characteristics, pre-treatment pathology) as covariates (Hedeker &
Gibbons, 1997).
Results
Participant Selection and Randomization
See Figure 2 for a CONSORT diagram of participant flow through the study. Seven
hundred and forty students took the prescreening measure during the Fall 2013, Spring 2014, and
Fall 2014 semesters. Twenty-two percent were excluded due to elevated eating pathology
(EAT>20), and 38% were ineligible because they reported minimal body image concerns
(WCS<34). Therefore, 50% of participants (N=371) were found eligible for the study. Of these
eligible participants, 278 completed the baseline questionnaire and were randomized to DBI-I
(n=93), CBT-I (n=90), or NT (n=95).
Baseline Characteristics
Demographic characteristics are summarized in Table 1. Forty-one percent of participants
were of Asian descent, 33% White, 12% Latino, 7% Multi-ethnic, 6% Black, and 1% Other. The
mean age for the sample was 20.89 years (SD=3.20). The mean BMI was 22.04 (SD=3.67), a
value in the “Normal” (healthy weight) category (Centers for Disease Control and Prevention,
2015). A series of one-way ANOVA analyses indicated that the three study groups (DBI-I, CBT-
I, NT) did not vary on baseline pathology or demographic characteristics.
Attrition
Seventy-two percent of participants (n=201) completed the post-treatment assessment.
Dropout rates for DBI-I, CBT-I, and NT were 33.3% (n=31), 35.5% (n=27), and 18.9% (n=18),
respectively. When dropout rates were compared for the three study conditions, a marginally
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22
significant effect was detected, χ
2
(2)=5.52, p=.06. To explore this effect further, pairwise
comparisons were conducted. Participants in the DBI-I condition were significantly more likely
to drop out than NT participants, χ
2
(1)=5.05, p<.05. Dropout was marginally more likely for
CBT-I than NT, χ
2
(1)=3.39, p=.07. No difference in dropout frequency was found between and
DBI-I and CBT-I.
Demographic characteristics (age, BMI, GPA) and baseline pathology (composite eating
symptoms, body dissatisfaction, dieting, thin-ideal internalization, depression) were compared
between T2 dropouts and completers in a series of independent samples t-tests. Attrition on the
basis of ethnicity was evaluated using chi-square analyses. Study dropout was more likely for
participants with higher body dissatisfaction, t(276)=5.19, p<.05. In addition, a marginally
significant effect was detected for ethnicity (White vs. Asian vs. “Other”), χ
2
(2)=5.39, p=.07.
Pairwise comparisons indicated that dropout was more likely for participants in the “Other”
ethnic category than for Asians, χ
2
(1)=4.46 p< .05, and marginally more likely for “Other”
participants than for Whites, χ
2
(1)=3.61, p=.06. Dropout did not differ between Whites and
Asians. Effects for the remaining demographic and symptom traits were non-significant.
As mentioned previously, a dummy-coded variable denoting post-treatment study
dropout (0 = No, 1 =Yes) was included in all analyses to produce unbiased parameter estimates.
Results did not differ between models that included the dropout covariate and those that did not.
Therefore, outcomes for the baseline model without missingness covariates are reported.
Treatment Engagement and Process
Seventy-five percent of participants in the active treatment conditions (DBI-I and CBT-I)
completed at least one session. Session completion rates are presented in Table 2. Regarding
differences between DBI-I and CBT-I, 74% of participants randomized to DBI-I completed at
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least one treatment session, compared to 77% of CBT-I participants. This difference was not
statistically significant, χ
2
(1)=1.07, p=.59. Due to a technical error, participant identifiers were
removed for 137 of the 181 participants in session 4. This precluded calculation of a session total
score for the vast majority (76%) of the sample. As a result, the association between total number
of sessions completed and study outcomes could not be evaluated. However, data for homework
completion, a second measure of engagement, were successfully linked to study participants.
Rates of homework completion for each of the individual sessions did not differ between
conditions (Table 3). Furthermore, the mean total number of completed homework assignments
did not differ for the two active treatment conditions, t(179)=.09, p=.93. I also evaluated total
number of homework assignments completed as a predictor of each of the main study outcomes
(Table 4). For each outcome variable, a regression analysis was carried out in two steps. Pre-
treatment Pathology and Total Homework Assignments were included as predictors in step one
of the regression analyses. Condition and a ConditionXHomework interaction term were entered
in step two. The results indicated that total assignments completed was a significant negative
predictor of post-treatment eating pathology, B=-.82, SE=.35, p=.02. Also, assignments
completed was a marginally significant predictor of post-treatment depression, B=-.15, SE=.08,
p=.06. However, for each outcome, the interaction between homework assignments and
condition was non-significant, suggesting that the effect of homework completion on post-
treatment outcomes did not vary between DBI-I and CBT-I.
Means and standard deviations for intra-session outcomes are presented in Table 5.
Independent samples t-tests were performed to examine whether scores for these process-related
variables varied between treatment conditions at the end of each of the four treatment sessions. It
was hypothesized that post-session dissonance would be higher for DBI-I than CBT-I, and that
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post-session thin-ideal internalization would be higher for CBT-I than DBI-I. I also expected that
post-session negative body cognitions would be lower for CBT-I than DBI-I. As predicted, at the
end of the first session, participants in DBI-I reported higher dissonance than participants in
CBT-I, t(127)=-2.57, p=.01. Post-session body cognitions and thin-ideal internalization did not
vary between groups at the end of the first treatment session. For the remaining sessions (2-4), no
group differences were found for post-session dissonance, thin-ideal internalization, or negative
body cognitions.
Main Outcomes
Raw means and standard deviations for each outcome variable at pre- and post-treatment
are provided in Table 6. Results for regression analyses evaluating treatment effects for the
primary outcomes, as well as effect sizes for group differences in adjusted post-treatment means,
are presented in Table 7. Following Cohen’s guidelines, an effect size of 0.20 is considered
“small”, 0.50 is “medium”, and 0.80 is “large” (Cohen, 1988). Figures 3-7 provide plots of the
observed means for each outcome at pre- and post-treatment.
Composite eating pathology. For composite eating pathology, the omnibus condition
effect was significant, Wald χ
2
(2)=9.58, p<.01. Relative to NT, CBT-I participants showed
greater reductions in composite eating pathology at post-treatment, B=-3.75, SE=1.21, p<01. No
other group differences were found.
Body dissatisfaction. The overall condition effect for body dissatisfaction was
significant, Wald χ
2
(2)=18.09, p<.001. CBT-I was marginally better at reducing body
dissatisfaction than DBI-I (B =-7.85, SE=4.26, p=.07), and was significantly more effective than
NT, B =-17.27, SE=4.08, p<.001. DBI-I participants also showed greater reductions in body
dissatisfaction when compared with NT, B =-9.42, SE=4.07, p= 02.
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Thin-ideal internalization. The omnibus condition effect for thin-ideal internalization
was significant, Wald χ
2
(2)=17.17, p<.001. DBI-I was more effective at reducing thin-ideal
internalization than NT, B=-2.69, SE=.67, p<.001. CBT-I led to greater reductions in thin-ideal
internalization than NT as well, B =-1.79, SE=.67, p<.01. Intervention effects did not differ
between CBT-I and DBI-I.
Dieting. A significant condition effect was detected for dieting, Wald χ
2
(2)=10.33, p<.01.
CBT-I was more effective at reducing dieting than DBI-I, B=-2.25, SE=.99, p<.05. CBT-I also
led to greater decreases in dieting relative to NT, B =-2.97, SE=.94, p<.01. No difference was
found between DBI-I and NT.
Depression. The omnibus condition effect for depression was significant, Wald
χ
2
(2)=11.29, p<.01. CBT-I led to greater reductions in depression than NT, B =-2.92, SE=1.07,
p<.01. DBI-I showed significantly lower depression than NT, B=-3.17, SE=1.07, p=.83. Again,
no difference was found between CBT-I and DBI-I.
Main Outcome Summary
Omnibus condition effects were significant for each study outcome, suggesting that
internet-based intervention is an efficacious strategy for the reduction of ED risk factors.
Regarding specific group differences, DBI-I and CBT-I were each associated with greater
reductions in body dissatisfaction, thin-ideal internalization, and depression than NT. CBT-I also
led to greater reductions in eating pathology and dieting than NT; in contrast, no difference in
post-treatment dieting or composite eating pathology was found between DBI-I and NT. Also,
CBT-I was associated with less dieting and marginally lower body dissatisfaction than DBI-I; no
other outcome differences were found between the two active conditions.

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Mediation Analyses
Composite eating pathology. The CBT-I/DBI-I, CBT-I/NT and DBI-I/NT dummy
variables were tested as predictors of composite eating pathology in three separate mediation
models (Table 8). Total (i.e., combined) and specific effects for the two mediating variables were
evaluated. A contrast parameter estimate was generated to test for differences in the magnitude
of the indirect effects. Figures 8-10 each provide a graphical depiction of the multiple mediation
results.
When the CBT-I/DBI-I dummy variable was entered as a predictor term, the total indirect
effect of body dissatisfaction and thin-ideal internalization was significant, suggesting that the
two variables collectively mediated the effect of treatment on eating pathology. The specific
indirect effect of body dissatisfaction was significant, while the specific indirect of thin-ideal
internalization was not. However, contrast analyses indicated that the magnitude of the body
dissatisfaction mediation effect did not differ significantly from that of thin-ideal internalization.
For the CBT-I/NT predictor, the total indirect effect of thin-ideal internalization and body
dissatisfaction was significant. Again, the mediation effect for body dissatisfaction was
significant, while the mediation effect for thin-ideal internalization was non-significant. The
contrast coefficient was significant, indicating that the indirect effect was significantly larger for
body dissatisfaction than thin-ideal internalization.
The total indirect effect was not significant for the DBI-I/NT predictor term. However, a
significant mediation effect was found for body dissatisfaction. No mediation effect was found
for thin-ideal internalization. The contrast coefficient was significant; the indirect effect of body
dissatisfaction was significantly larger than that of thin-ideal internalization.
It is noteworthy that though the CBT-I/DBI-I and DBI-I/NT dummy variables did not
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27
directly predict eating pathology, significant mediation occurred. For the CBT-I/DBI-I effect, the
results indicated that participation in CBT-I predicted greater reductions in body dissatisfaction
than DBI-I, which in turn led to reductions in eating pathology. For the DBI-I/NT effect, the
results showed that participation in DBI-I was associated with greater reductions in body
dissatisfaction than NT, leading to lower post-treatment eating pathology.
Dieting. I also tested CBT-I/DBI-I, CBT-I/NT and DBI-I/NT as predictors in three
separate mediation models with dieting as the outcome variable (Table 9). Graphical
representations of the mediation results are provided in Figures 11-13. For the CBT-I/DBI-I
predictor term, the total indirect effect of body dissatisfaction and thin-ideal internalization was
not significant. Also, the specific effects for body dissatisfaction and thin-ideal internalization
were not significant. However, contrast analyses indicated that the specific indirect of body
dissatisfaction was significantly larger than that of thin-ideal internalization.
When the CBT-I/NT dummy variable was included as the predictor term, the total
indirect effect of the two mediator variables was significant. The specific indirect for body
dissatisfaction was significant, while the specific indirect effect for thin-ideal internalization was
not. Also, the indirect effect of body dissatisfaction was significantly greater than that of thin-
ideal internalization.
The total indirect effect was significant when DBI-I/NT was tested as the predictor.
When the mediator variables were tested separately, the mediating effect of body dissatisfaction
was significant, while the mediating effect of thin-ideal internalization was not. The contrast
coefficient was non-significant, indicating that the indirect effects did not differ in magnitude.
Given that significant specific indirect effects can occur despite a non-significant total indirect
effect (Preacher & Hayes, 2008), the results suggest that body dissatisfaction accounted for the
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association between treatment condition and dieting.
Statistically Reliable Change
I followed guidelines provided by Jacobson and Truax (1991) to calculate the Reliable
Change Index (RC) from pre-treatment to post-treatment (Table 10). The index provides a metric
for examining whether observed changes in outcomes are clinically significant. RC was derived
using the conservative approach to calculating the standard error of measurement of the
difference recommended by Maassen (2004).
The omnibus condition effect for reliable change was significant for body dissatisfaction,
thin-ideal internalization, and dieting. Rates of reliable change for these three outcomes were
significantly higher for participants in either of the active treatment conditions when compared to
NT. Reliable change frequencies did not differ between CBT-I and DBI-I for any outcome.
Discussion
This study aimed to evaluate the efficacy of two forms of internet-based ED prevention.
The results supported the efficacy of internet intervention, as the omnibus effect of treatment was
significant for all measured outcomes. Both CBT-I and DBI-I demonstrated efficacy for the
reduction of body dissatisfaction, depression, and thin-ideal internalization when compared with
NT. CBT-I was more effective at reducing dieting and composite eating pathology than NT.
DBI-I, on the other hand, did not lead to improvements in either eating outcome. When the
active conditions were compared, CBT-I led to greater reductions in dieting than DBI-I, and
marginally significant effects favoring CBT-I were found for body dissatisfaction. For the
remaining outcomes (thin-ideal internalization, eating pathology, depression), CBT-I and DBI-I
did not differ from each other.
Whereas both DBI-I and CBT-I reduced ED risk factors when compared to NT (body
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dissatisfaction, thin-ideal internalization), only CBT-I had a direct effect on eating behaviors.
Though prior research has supported DBI as an efficacious treatment for ED prevention, CBT is
well supported for threshold eating pathology (Murphy et al., 2010). The study provides
preliminary evidence that while DBI is consistently effective at reducing psychological risk
factors for ED relative to control, CBT is effective at reducing both ED risk factors and current
eating behaviors.
Effect sizes for CBT-I (vs. NT) ranged from small to moderate, with the largest effect
occurring for body dissatisfaction. Similarly, a prior trial of internet CBT reported a larger effect
for body dissatisfaction than other measures (Heinicke et al., 2007). Thus, it appears that effect
sizes for the CBT-I intervention correspond with findings from past research. With the exception
of thin-ideal internalization (d=.64), effect sizes for the DBI-I vs. NT comparison were in the
“small” range. A prior trial of an internet DBI program obtained an effect size of .63 for thin-
ideal internalization (Stice et al., 2012), which is comparable to the current study. However, for
other outcomes (e.g., body dissatisfaction, dieting, negative affect) effect sizes in my study were
smaller than those reported by Stice et al. (2012).
This is the first known study to reports effect sizes for a comparison of DBI with CBT.
DBI has yielded small post-treatment effects when compared with alternative treatment
strategies such as healthy weight control, expressive writing, yoga, and media advocacy (Stice et
al., 2008). Although my study is the first to identify an ED prevention program that is more
efficacious than DBI, effect sizes in favor of CBT-I were small.
Body dissatisfaction and thin-ideal internalization were examined as mediators of
CBT-I/DBI-I treatment effects, in order to evaluate whether theory-specific mechanisms were
associated with changes in eating behaviors. For eating pathology, a significant mediation effect
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was found for body dissatisfaction, but not thin-ideal internalization. The indirect effects of body
dissatisfaction and thin-ideal internalization did not differ in magnitude. For dieting, while the
indirect effect of body dissatisfaction was larger than that of thin-ideal internalization, neither
indirect effect was statistically significant. Accordingly, the results do not support either
mediator as a mechanism of change specific to DBI-I or CBT-I.
I also conducted mediation analyses comparing outcomes for the active conditions with
NT. I hypothesized that body dissatisfaction would mediate CBT-I effects, and that thin-ideal
internalization would mediate treatment effects for DBI-I. For the CBT-I vs. NT comparison,
body dissatisfaction was a significant mediator of treatment effects for composite eating
pathology and dieting. No mediation effect was found for thin-ideal internalization. Contrast
analyses showed that the indirect effect of body dissatisfaction was significantly larger than that
of thin-ideal internalization. Regarding the DBI-I vs. NT comparison, although DBI-I did not
affect composite eating pathology or dieting directly, I found significant mediation effects for
body dissatisfaction. DBI-I led to greater reductions in body dissatisfaction than NT. Decreased
body dissatisfaction, in turn, predicted change in eating behaviors.
Thus, body dissatisfaction emerged as a mediator of therapy outcomes regardless of
treatment condition. This finding could be explained by the fact that both interventions focused
heavily on challenging pre-existing body image beliefs. Also, both interventions encouraged
participants to consider how body image affects interpersonal relationships. Prior ED prevention
programs with diverse theoretical perspectives have identified body dissatisfaction as a mediator
of treatment outcomes (Seidel et al., 2009; Dingemans et al., 2007). Given that body
dissatisfaction is a leading predictor of ED onset (Stice, Marti, & Durant, 2007), it is possible
that reducing body dissatisfaction is associated with reduced maladaptive eating behavior
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regardless of treatment paradigm.
In contrast with prior DBI research (Stice et al, 2007; Stice et al., 2011), I did not find
significant thin-ideal internalization mediation effects. Body dissatisfaction is strongly associated
with eating pathology, and body image disturbance is included as a diagnostic criterion for
anorexia nervosa and bulimia nervosa (American Psychiatric Association, 2013). It could be that
the endorsement of cultural body image norms is less proximal to the development of ED
symptoms, attenuating the influence of thin-ideal internalization on treatment outcomes. Also,
prior investigations of thin-ideal internalization as a mediator of DBI effects have recruited study
populations with minimal pre-treatment pathology (Stice et al, 2007; Stice et al., 2011), while
elevated weight concerns were a requirement for inclusion in the current study. It is possible that
thin-ideal internalization exerts a weaker effect on eating pathology in higher risk samples.
Specificity of treatment mechanisms was also examined by comparing scores on body-
related thoughts and dissonance within sessions. It was expected that post-session dissonance
would be higher for DBI-I than CBT-I, while post-session negative body thoughts would be
lower for CBT-I than DBI-I. DBI-I yielded higher dissonance relative to DBI-I immediately after
the first treatment session, but this effect did not occur in sessions 2-4. Condition differences in
body image thoughts did not occur for any of the sessions. These results provide further evidence
of similar treatment mechanisms for CBT-I and DBI-I.
The utilization of a direct comparison between two bona fide psychotherapies was well
suited to identifying differential mechanisms of change for CBT-I and DBI-I. However, it is
possible that common factors accounted for therapeutic change in both conditions. The
therapeutic alliance is commonly cited as a mechanism of change in various psychotherapies
(Elvins & Green, 2008; Kazdin & Nock, 2003; Kazdin, 2007). However, given the remote nature
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of treatment delivery and paucity of contact between participants and study personnel in both
intervention conditions, there may be other factors that are more relevant to the current study.
Examples of common factors that were present in both CBT-I and DBI-I include 1) persuading
participants to change; 2) enhancement of personal and emotional learning; 3) fostering insight
and awareness; and 4) provision of information and education (Tracey, Lichtenberg, &
Goodyear, 2003). It is also worth noting that both interventions were cognitively oriented.
Though DBI-I adopted a sociocultural perspective, and CBT-I attended primarily to the internal
emotional experience, both conditions actively encouraged participants to challenge previously
held thoughts and assumptions about their bodies. These shared traits might account for lack of
mechanism specificity between the two interventions.
Program Adherence and Process
Seventy-five percent of participants who were randomized to CBT-I or DBI-I accessed at
least one treatment session. Though sub-optimal, this figure does not differ substantially from
treatment initiation rates in past internet-based interventions for eating pathology (e.g., Fichter et
al., 2012). The majority of participants completed at least one homework assignment as well;
overall, uptake of the interventions was acceptable. Nevertheless, future studies should examine
strategies to facilitate program exposure. Internet intervention characteristics associated with
greater participant engagement include peer support, counselor support, email contact, and
regular updating of website components (Brouwer et al., 2011). As this intervention did not
include peer or counselor support, it is possible that more interpersonal elements would have
fostered greater program adherence.
Assessment dropout rates were significantly higher for the active conditions when
compared to NT. This outcome corresponds with past research, as several studies evaluating
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web-based interventions have reported higher assessment dropout for active condition
participants than controls (e.g., Murray et al, 2010; Twomey et al., 2014). No pre-treatment
differences in demographic or symptom characteristics were found between the active conditions
and NT, reducing the likelihood that participant-level characteristics contributed to the difference
in dropout rates. One potential explanation is that active condition participants were more likely
to become desensitized to study communications due to higher frequency of email contact. CBT-
I and DBI-I participants received several emails a week that included reminders to complete
study sessions and homework assignments. For this reason, it is possible that they were more
likely than NT participants to overlook or ignore the email containing a link to the post-treatment
assessment. Murray et al. (2010) speculated that active intervention participants were more likely
to drop out from a web-based alcohol intervention than a placebo control condition because they
had received an adequate dose of the intervention during treatment. The authors argue that
control participants, on the other hand, had unmeet need at the conclusion of treatment and
therefore sustained contact with the researchers. Because reasons for dropout were not assessed
directly in the current study, the exact cause of higher dropout in the active conditions remains
unknown. Future research on electronic ED intervention should prioritize assessing participant
reasons for dropout, as this might elucidate the trend of higher experimental group attrition.
I conducted regression analyses to examine whether homework completion predicted
treatment outcomes. The results showed that number of assignments completed was a predictor
of composite eating pathology, and a marginally significant predictor of dieting. The strength of
this effect did not vary by treatment condition. Murdoch and Connor-Greene (2000) posited that
homework assignments enhance therapeutic impact and increase effectiveness by encouraging
participants to attend to therapy-related issues outside of the session. The authors praised
EATING DISORDER PREVENTION

34
computer technology as a convenient method for distributing and monitoring homework
activities. My findings correspond with prior research identifying homework completion as a
predictor of positive therapy outcome (Kazantzis, Whittington, & Dattilio, 2010).
Internet Intervention as a Strategy for Therapeutic Change
Because the study did not include a face-to-face comparison condition, it is difficult to
ascertain the extent to which internet delivery uniquely affected treatment outcomes. Prior
research studies comparing internet interventions with face-to-face programs have reported
comparable effects at post-treatment (Stice et al., 2012) and follow-up (Heinicke et al. 2007,
Stice et al., 2012). DBI-I might facilitate greater dissonance exposure than the Body Project
protocol, because each individual generates more responses to dissonance prompts than is typical
in the group-based, face-to-face version of the program (P. Rohde, personal communication,
December 4, 2012). Considering that CBT prevention programs also tend to utilize a group
format, the advantage of increased exposure to program components could generalize to CBT-I
as well. Furthermore, use of internet intervention facilitated the automation of program
components to a greater extent than is possible with face-to-face treatment. Considering that a
structured format is associated with enhanced ED prevention outcomes (Stice & Shaw, 2004), it
is possible that this contributed to the efficacy of the active intervention conditions. More
research with face-to-face comparison groups is needed to determine the extent to which these
web-specific features enhance outcomes relative to traditional treatments.
Limitations
Several limitations to the study exist. Because data were collected from undergraduates
who were incentivized to participate in the study, it is possible that these results are not
applicable to the general population. Another factor that may limit generalization is the restricted
EATING DISORDER PREVENTION

35
range of eating pathology in the sample. Approximately 20% of potential participants were
excluded from the study due to elevated eating pathology, truncating the distribution of eating
pathology in the sample. Consequently, I am unable to draw conclusions regarding the efficacy
of the interventions for the reduction of severe eating behaviors.
Furthermore, this research focuses on post-treatment outcomes due to marked study
attrition at follow-up. As a result, the longer-term effects of the treatments are unknown. Also,
though I controlled for pre-treatment scores, mediation analyses were cross-sectional; thus, it is
unclear whether changes in body dissatisfaction preceded changes in eating behaviors, or vice
versa.
Regarding treatment content, my study had few interactive elements. Because past
research has suggested that therapist-client interaction enhances treatment outcomes (Stice et al.,
2007), it is possible that the inclusion of interpersonal elements would have led to larger
treatment effects. It should also be noted that because the study was administered remotely, the
setting of participant access might have varied considerably. This is a factor unrelated to the
research design that could have affected my findings.
Study Strengths
The study provides support for internet intervention as an efficacious strategy for
reducing body image and eating pathology. Despite minimal social interaction and a self-guided
format, significant omnibus intervention effects were obtained. The automated features of the
active interventions allowed me to disseminate the program with minimal overhead costs when
compared to face-to-face intervention. Automation of program components ensured that each
participant received a similar version of the intervention, reducing the therapist-specific error
that can occur with face-to-face studies (Kim, Wampold, & Bolt, 2006).
EATING DISORDER PREVENTION

36
Regarding potential implications of the research, the preventive nature of both programs
could contribute to the reduction of future ED incidence. As EDs are among the most expensive
psychological disorders to treat and require highly intensive services (Striegel ‐ Moore, Leslie,
Petrill, Garvin, & Rosenheck, 2000), internet-based protocols such as those utilized in the current
study might alleviate public healthcare expenses associated with ED treatment at minimal cost to
patients and service providers. This research contributes to current knowledge regarding ED
prevention, internet-administered psychosocial interventions, and the viability of alternative DBI
and CBT formats.
Future Directions
I offer several recommendations for the design and implementation of future internet-
based ED prevention programs. Evidence was obtained suggesting that body dissatisfaction is a
mechanism of ED prevention effects, regardless of treatment paradigm. It would behoove
treatment researchers to implement controlled trials that compare active interventions to identify
specific ingredients that promote therapeutic change. This research design is rare in the ED
prevention literature, limiting knowledge of mechanisms associated with positive treatment
outcomes for those at risk. Also, as noted earlier, a wealth of empirical support for the efficacy of
DBI exists (e.g., Stice, Presnell, Gau, & Shaw, 2007; Stice, Rohde, Durant, & Shaw, 2014).
However, given that the current study showed CBT-I to be an efficacious strategy for the
reduction of maladaptive eating behaviors, I recommend continued evaluation of the cognitive-
behavioral paradigm for ED prevention.
Also, future research should continue examining the potential of interventions adapted for
mobile formats that fully utilize the enhanced accessibility of internet-based intervention. For
example, Bauer et al. (2012) reported positive outcomes for a text messaging intervention
EATING DISORDER PREVENTION

37
designed to reduce bulimic pathology. Finally, I recommend further exploration of whether
therapist guidance enhances treatment outcomes; the literature to date suggests that this is the
case (e.g., Stice et al., 2007). Bauer and Moessner (2013) argue that because self-guided
interventions can be disseminated widely, attenuated effects due to low therapist contact are a
reasonable cost given the potential of wide reach to the general population. Though I agree with
this assessment, I hope that future research pursues strategies to optimally balance therapist
contact and reach of dissemination.
Conclusions
My results support the efficacy of web-based intervention for body image and eating
disturbances. DBI-I and CBT-I tended to be more efficacious than NT, and CBT-I showed
greater efficacy in reducing eating behaviors when compared to DBI-I. Also, a trend emerged
favoring CBT-I over DBI-I for the reduction of body dissatisfaction. Evidence for body
dissatisfaction as a mechanism of change was obtained, although thin-ideal internalization was
not supported as a mediator of treatment effects. Effects for intra-session outcome measures and
incidence of clinically significant change did not differ between CBT-I and DBI-I. For future
research, I recommend that investigators compare the efficacy of varying treatment approaches,
explore the application of mobile technology for ED prevention, and examine strategies to
incorporate therapist guidance in the context of remotely delivered treatment.
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38
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Appendix A:
Tables and Figures
Table 1

Baseline Demographics and Clinical Characteristics of the Sample
Total
(n=278)
DBI-I
(n=93)
CBT-I
(n=90)
NT
(n=95)
F χ
2
Age (years), M(SD) 20.89 (3.19) 20.68 (3.57) 21.26 (3.80) 20.74 (1.95) .89 -
Body Mass Index (BMI), M(SD) 22.04 (3.69) 22.22 (3.68) 22.32 (3.23) 21.60 (4.07) 1.03 -
Eating Pathology, M(SD) 9.75 (7.49) 100.27 (28.73) 9.72 (7.62) 10.44 (8.14) .75 -
Body Dissatisfaction, M(SD) 99.24 (29.68) 31.71 (8.49) 97.97 (26.85) 99.45 (33.21) .29 -
Thin-Ideal Internalization, M(SD) 23.68 (3.10) 24.17 (2.95) 23.23 (3.25) 23.62 (3.06) 2.10 -
Dieting, mean M(SD) 29.16 (7.09) 28.97 (6.14) 29.98 (7.53) 28.55 (7.49) .74 -
Depression, M(SD) 30.32 (7.89) 31.71 (8.49) 29.04 (7.42) 30.16 (7.57) 2.20 -

Ethnicity 6.83
Asian, n (%) 113 (40.6) 40 (43.0) 36 (40.0) 37 (38.9) -
White, n (%) 91 (32.7) 27 (29.0) 31 (34.4) 33 (34.7) -
Latino, n (%) 34 (12.2) 12 (12.9) 13 (14.4) 9 (9.5) -
Black, n (%) 16 (5.8) 7 (7.5) 5 (5.6) 4 (4.2) -
Multi-ethnic, n (%) 20 (7.2) 5 (5.4) 5 (5.6) 10 (10.5) -
Other, n (%) 4 (1.4) 2 (2.2) 0 (0.0) 2 (2.1) -
Note. *p < .05. DBI-I = internet dissonance-based intervention. CBT-I = internet cognitive-behavioral treatment. NT = no treatment. BMI = body mass index.

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Table 2
DBI-I vs. CBT-I Session Completion Summary

Total
(n=181)
DBI-I
(n= 93)
CBT-I
(n=88 ) χ
2
p
n (%) n (%) n (%)
Session 1 128 (70.7) 69 (74.2) 59 (67.0) 1.39 .24
Session 2 132 (72.9) 68 (73.9) 64 (72.7) .03 .86
Session 3 114 (63.9) 59 (63.4) 55 (62.5) .05 .82
Session 4 126 (69.6) 63 (67.7) 63 (71.5) .32 .57
Note. *p<.05. DBI-I = internet dissonance-based intervention. CBT-I = internet cognitive-behavioral treatment.
Percentages denote rates of session completion.

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Table 3
DBI-I vs. CBT-I Homework Completion Summary

Total DBI-I
(n= 93)
CBT-I
(n=88 ) χ
2
t p

n (%) n (%)
Session 1

56 (60.2) 47 (53.4) .85 .36
Session 2

54 (58.1) 50 (56.8) 1.07 .59
Session 3

49 (52.7) 48 (54.5) 1.17 .56
Session 4

48 (51.6) 44 (50.0) 1.08 .59

M (SD) M (SD)
Total Complete

2.23 (1.66) 2.25 (1.78) .09 .93
Note. DBI-I = internet dissonance-based intervention. CBT-I = internet cognitive-behavioral treatment. Percentages
denote rates of homework completion for each treatment session.
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Table 4
Tests of Homework Completion as Predictor of Primary Study Outcomes
Outcome Step Predictor B SE B t p
EAT 1 T1 EAT .53 .07 7.22 <.001*
Total Homework Assignments -.82 .35 -2.34 .02*
2 Condition -.17 .16 -1.06 .29
Total Homework Assignments X Condition .02 .17 .14 .88

BSQ 1 T1 BSQ .62 .06 11.11 .<001*
Total Homework Assignments -.09 .08 -1.22 .22
2 Condition -9.38 9.59 -.98 .32
Total Homework Assignments X Condition .33 2.95 .11 .91

IBSS 1 T1 IBSS .12 .12 .99 .32
Total Homework Assignments -.22 .27 -.81 .42
2 Condition -.22 1.79 -.12 .90
Total Homework Assignments X Condition .28 .55 .51 .61

DRES 1 T1 DRES .74 .07 9.85 <.001*
Total Homework Assignments -.54 .35 -1.53 .13
2 Condition -.83 2.28 -.37 .71
Total Homework Assignments X Condition -.54 -.70 -.78 .43

BDI 1 T1 BDI .57 .06 9.80 <.001*
Total Homework Assignments -.15 .08 -1.87 .06
2 Condition -.08 .16 -.48 .63
Total Homework Assignments X Condition .08 .17 .46 .64
Note. *p < .05. Outcome variables were measured at post-treatment. Step 1 variables were included as covariates in Step 2 analyses.
EAT = Eating Attitudes Test. Condition was coded DBI-I = 0, CBT-I = 1. BSQ = Body Shape Questionnaire. IBSS = Ideal Body Stereotype Scale. DRES =
Dutch Restrained Eating Scale. BDI = Beck Depression Inventory.

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Table 5
DBI-I vs. CBT-I Comparison of Intra-session Outcome Measures

DBI-I
M (SD)
CBT-I
M (SD) t
Session 1 BTQ 33.07 (5.19) 32.14 (7.53) .79
IBSS 22.57 (3.26) 22.56 (3.26) .32
DISS 87.23 (14.06) 79.70 (15.23) 2.87*

Session 2 BTQ 34.20 (4.99) 33.91 (6.63) .28
IBSS 22.00 (3.23) 22.56 (3.26) .27
DISS 87.23 (14.69) 86.42 (14.50) .32

Session 3 BTQ 36.00 (5.21) 34.36 (6.88) 1.45
IBSS 21.03 (4.02) 21.06 (3.63) .05
DISS 88.97 (14.46) 14.71 (1.93) .42

Session 4 BTQ 36.89 (5.81) 36.38 (6.32) .46
IBSS 20.19 (4.36) 20.33 (4.72) .19
DISS 90.57 (17.32) 90.62(13.33) .01
Note. *p <.05. DBI-I = internet dissonance-based intervention. CBT-I = internet cognitive-behavioral treatment.
BTQ = Body Thoughts Questionnaire. IBSS = Ideal Body Stereotype Scale. DISS = Dissonance Proxy Scale.

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Table 6

Raw Means and Standard Deviations of Primary Outcome Variables at Each Time Point

Baseline Post-treatment
Outcome DBI-I
(n=93)
CBT-I
(n=90)
NT
(n=95)
DBI-I
(n=61)
CBT-I
(n=60)
NT
(n=75)
Eating Pathology, M(SD) 9.05(6.55) 9.8 (7.66) 10.39 (8.18) 6.97 (7.89) 5.32 (5.97) 8.96 (10.06)
Body Dissatisfaction, M(SD) 100.66 (28.43) 99.52 (27.03) 97.42 (33.28) 88.44 (32.58) 77.44 (27.31) 91.60 (31.72)
Thin-Ideal Internalization, M(SD) 24.19 (2.94) 23.30 (3.15) 23.54 (3.17) 20.85 (4.95) 21.37 (3.94) 23.22 (3.21)
Dieting, M(SD) 29.21 (6.18) 29.78 (7.54) 28.52 (7.48) 26.85 (7.78) 25.51 (7.17) 27.32 (7.45)
Depression, M(SD) 31.69 (8.47) 29.44 (7.57) 29.79 (7.49) 28.50 (6.86) 27.05 (7.50) 30.39 (8.83)
Note. DBI-I = internet dissonance-based intervention. CBT-I = internet cognitive-behavioral treatment. NT = no treatment. Post-treatment means and standard
deviations are reported for completers of each assessment period.
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Table 7
Regression Results for Primary Study Outcomes
Outcome
Treatment
Comparison B SE B t d p
EAT DBI-I vs. CBT-I -1.91 1.27 -1.50 .27 .133
DBI-I vs. NT -1.85 1.20 1.54 .20 .123
CBT-I vs. NT -3.75 1.21 -3.09 .45 .002

BSQ DBI-I vs. CBT-I -7.85 4.26 -1.84 .26 .066
DBI-I vs. NT -9.42 4.07 -2.31 .29 .021
CBT-I vs. NT -17.27 4.08 -4.23 .58 <.001

IBSS DBI-I vs. CBT-I .10 .08 1.28 .20 .202
DBI-I vs. NT -2.69 .67 -4.02 .64 <.001
CBT-I vs. NT -1.79 .67 -2.65 .49 .008

DRES DBI-I vs. CBT-I -2.25 .99 -2.27 .29 .023
DBI-I vs. NT -.72 .93 -.77 .09 .439
CBT-I vs. NT -2.97 .94 -3.13 .39 .002

BDI DBI-I vs. CBT-I .25 1.13 .22 .03 .825
DBI-I vs. NT -3.17 1.07 2.97 .40 .003
CBT-I vs. NT -2.92 1.07 -2.72 .36 .007
Note. DBI-I = internet dissonance-based intervention. CBT-I = internet cognitive-behavioral treatment. NT = no
treatment. EAT = Eating Attitudes Test. BSQ = Body Shape Questionnaire. IBSS = Ideal Body Stereotype Scale.
DRES = Dutch Restrained Eating Scale. BDI = Beck Depression Inventory. The DBI-I vs. CBT-I contrast variable
was dummy coded 0 = DBI-I, 1 = CBT-I. The DBI-I vs. NT contrast variable was dummy coded 0 = NT, 1 = DBI-I.
The CBT-I vs. NT condition contrast variable was dummy coded NT = 0, CBT-I = 1. Between-group effect sizes
(Cohen’s d) using adjusted means are presented.

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Table 8

Tests of Mediators of the Association Between Treatment Condition and Composite Eating
Pathology
Bootstrapping
Treatment
Comparison Mediator
Point
Estimate
Product of
Coefficients BC 95% CI
SE Est./SE Lower Upper
Indirect Effects
CBT-I/DBI-I BSQ -1.35 .79 -1.72 † -3.09 -.03
IBSS -.05 .11 -.47 -.48 .06
Total -1.41 .79 -1.78* -3.15 -.08
Contrast
-1.29 .80 -1.62 -3.08 .06

Indirect Effects
CBT-I/NT BSQ -2.53 .91 -2.77* -4.78 -1.14
IBSS .15 .27 .57 -.22 .94
Total -2.37 .81 -2.94 -4.46 -1.18
Contrast
-2.68 1.07 -2.49 -5.33 -1.04

Indirect Effects
DBI-I/NT BSQ 1.67 .83 2.03* .32 3.60
IBSS -.39 .37 -1.04 -1.31 .22
Total 1.29 .78 1.65 -.19 2.91
Contrast
2.06 1.02 2.03* .51 4.63
Note. *p < .05. Figures in bold indicate that the 95% CI that does not include zero (i.e., p<.05). BC = bias corrected.
DBI-I = internet dissonance-based intervention. CBT-I = internet cognitive-behavioral treatment. NT = no treatment.
BSQ = Body Shape Questionnaire (measure of body dissatisfaction). IBSS = Ideal Body Stereotype Scale. The DBI-
I vs. CBT-I contrast variable was coded 0 = DBI-I, 1 = CBT-I. The CBT-I vs. NT condition contrast variable was
dummy coded NT = 0, CBT-I = 1. The DBI-I vs. NT condition contrast variable was dummy coded NT = 0, CBT-I
= 1.

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Table 9

Tests of Mediators of the Association Between Treatment Condition and Dieting
Bootstrapping
Treatment
Comparison Mediator
Point
Estimate
Product of
Coefficients BC 95% CI
SE Est./SE Lower Upper
Indirect Effects
CBT-I/DBI-I BSQ -1.06 .56 -1.78 † -2.22 .008
IBSS -.14 .22 .63 -.16 .79
Total -.87 .66 -1.31 -2.22 .37
Contrast
-1.14 .54 -2.11* -2.29 -.16

Indirect Effects
CBT-I/NT BSQ -2.34 .69 -3.36* -3.99 -1.22
IBSS -.34 .23 -1.51 -.88 .03
Total -2.68 .74 -3.64* -4.49 -1.51
Contrast
-1.99 .73 -2.73* -3.66 -.79

Indirect Effects
DBI-I/NT BSQ 1.30 .66 1.96* .19 2.86
IBSS .57 .44 1.29 -.09 1.66
Total 1.88 .79 2.38* .45 3.58
Contrast
.73 .80 .91 -.64 2.57
Note. Figures in bold indicate that the 95% CI that does not include zero (i.e., p < .05). BC = bias corrected. DBI-I=
internet dissonance-based intervention. CBT-I = internet cognitive-behavioral treatment. NT = no treatment. BSQ =
Body Shape Questionnaire. IBSS=Ideal Body Stereotype Scale. The DBI-I vs. CBT-I contrast variable was coded 0 =
DBI-I, 1 = CBT-I. The CBT-I vs. NT condition contrast variable was dummy coded NT = 0, CBT-I = 1. The DBI-I
vs. NT condition contrast variable was dummy coded NT = 0, CBT-I = 1.

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Table 10

Rates of Statistically Reliable Change by Condition

Statistically Reliable Change
n (%)

Study Outcome DBI-I
n=62
CBT-I
n = 59
NT
n =75 χ
2
(2) p
EAT 6 (9.7) 3 (5.1) 4 (5.3) 1.36 .506
BSQ 20 (44.4) 17 (37.8) 8 (17.8) 10.45 .005*
IBSS 11 (17.7) 7 (36.8) 1 (5.3) 10.89 .004*
DRES 22 (36.1) 24 (40.0) 14 (18.7) 8.38 .015*
BDI 12 (19.4) 10 (27.0) 15 (20.0) .21 .898
Note. *p < .05. DBI-I = internet dissonance-based intervention. CBT-I = internet cognitive-behavioral treatment. NT
= no treatment. EAT = Eating Attitudes Test. BSQ = Body Shape Questionnaire. IBSS = Ideal Body Stereotype
Scale. DRES = Dutch Restrained Eating Scale. BDI = Beck Depression Inventory. Reliable Change was calculated
for participants who completed the post-treatment assessment.

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Figure Captions
Figure 1. Hypothesized mediation model
Figure 2. Participant flow chart
Figure 3. Mean eating pathology by treatment condition
Figure 4. Mean body dissatisfaction by treatment condition
Figure 5. Mean thin-ideal internalization by treatment condition
Figure 6. Mean dieting by treatment condition
Figure 7. Mean depression by treatment condition
Figure 8. Mediation pathways for the association between treatment (CBT-I vs. NT) and composite
eating pathology

Figure 9. Mediation pathways for the association between treatment (CBT-I vs. NT) and composite
eating pathology

Figure 10. Mediation pathways for the association between treatment (DBI-I vs. NT) and composite
eating pathology

Figure 11. Mediation pathways for the association between treatment (CBT-I vs. DBI-I) and dieting

Figure 12. Mediation pathways for the association between treatment (CBT-I vs. NT) and dieting

Figure 13. Mediation pathways for the association between treatment (DBI-I vs. NT) and dieting

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Figure 1. Hypothesized Mediation Model

P
e
r
a1
=1
(c’)
Study
Condition
Contrast

Thin-ideal
Internalization

Body
Dissatisfaction
b1
a2
b2
Dieting/
Composite
Eating
Pathology
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Figure 2. Participant flow chart.

DBI-I = internet dissonance-based intervention; CBT-I = internet cognitive-behavioral treatment; NT = no treatment; EAT = Eating
Attitudes Test.
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Figure 3. Mean composite eating pathology by treatment condition.
Note. Observed means for T2 completers are presented.

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Figure 4. Mean body dissatisfaction by treatment condition.
Note. Observed means for T2 completers are presented.

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Figure 5. Mean thin-ideal internalization by treatment condition.
Note. Observed means for T2 completers are presented.

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Figure 6. Mean dieting by treatment condition.
Note. Observed means for T2 completers are presented.

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Figure 7. Mean depression by treatment condition.
Note. Observed means for T2 completers are presented.
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Figure 8. Mediation pathways for the association between treatment (CBT-I vs. DBI-I) and composite eating pathology.

Point estimates and standard error (SE) reported. †p < .10. DBI-I = internet dissonance-based intervention. CBT-I = internet
cognitive-behavioral treatment. Point estimate and standard error for indirect effects (ab), and bootstrapping estimates are reported in
Table 8.

P
e
r
CBT-I/
DBI-I
-7.94, SE=4.31†

Thin-ideal
Internalization

Body
Dissatisfaction
.17, SE=.02
Composite
Eating
Pathology
.63, SE=.13 -.09, SE=.09
c:-1.91, SE=1.27
c’: -.51, SE=.84
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Figure 9. Mediation pathways for the association between treatment (CBT-I vs. NT) and composite eating pathology.

Point estimates and standard error (SE) reported. CBT-I = internet cognitive-behavioral treatment; NT = no treatment. Point estimate
and standard error for indirect effects (ab), and bootstrapping estimates are reported in Table 8.

CBT-I/
NT
-17.34, SE=3.65

Thin-ideal
Internalization

Body
Dissatisfaction
.15, SE=.04
Composite
Eating
Pathology
-1.78, SE=.59 -.09, SE=.14
c: -3.75, SE=1.21
c’: -1.41, SE=.97
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Figure 10. Mediation pathways for the association between treatment (DBI-I vs. NT) and composite eating pathology.
Point estimates and standard error (SE) reported. DBI-I = internet dissonance-based intervention; NT = no treatment. Point estimate
and standard error for indirect effects (ab), and bootstrapping estimates are reported in Table 8.

DBI-I/
NT
-9.44, SE=4.27

Thin-ideal
Internalization

Body
Dissatisfaction
.18, SE=.03
Composite
Eating
Pathology
-2.84, SE=.64 -.14, SE=.13
c: -1.85, SE=1.20
c’: -.86, SE=1.21
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Figure 11. Mediation pathways for the association between treatment (CBT-I vs. DBI-I) and composite eating pathology.

Point estimates and standard error (SE) reported. †p < .10. DBI-I = internet dissonance-based intervention; CBT-I = internet
cognitive-behavioral treatment. Point estimate and standard error for indirect effects (ab), and bootstrapping estimates are reported in
Table 9.

P
e
r
CBT-I/
DBI-I
-7.94, SE=4.31†

Thin-ideal
Internalization

Body
Dissatisfaction
.13, SE=.02
Dieting
.13, SE=.19 .23, SE=.12†
c:-2.26, .99
c’: 1.08, .83
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Figure 12. Mediation pathways for the association between treatment (CBT-I vs. NT) and composite eating pathology.

Point estimates and standard error (SE) reported. †p < .10. CBT-I = internet cognitive-behavioral treatment; NT = no treatment. Point
estimate and standard error for indirect effects (ab), and bootstrapping estimates are reported in Table 9.

P
e
r
CBT-I/
NT
-17.35, SE=3.65

Thin-ideal
Internalization

Body
Dissatisfaction
.14, SE=.02
Dieting
-1.78, SE=.59 .19, SE=.11†
c: -2.97, SE=.94
c’: -.24, SE=.75
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Figure 13. Mediation pathways for the association between treatment (DBI-I vs. NT) and composite eating pathology.

Point estimates and standard error (SE) reported. DBI-I = internet dissonance-based intervention; NT = No Treatment. Point estimate
and standard error for indirect effects (ab), and bootstrapping estimates are reported in Table 9.
DBI-I/
NT
-9.45, SE=4.27

Thin-ideal
Internalization

Body
Dissatisfaction
.14, SE=.02
Dieting
.38, SE=.19 .20, SE=.15
c: -.72, SE=.93
c’: -1.11, SE=.79
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Appendix B:
Study Outcomes for Follow-up Assessment Completers

Table 1

Raw Means and Standard Deviations of Primary Outcome Variables at Each Time Point
Baseline Post-treatment 1-month follow-up
Outcome DBI-I
n=93
CBT-I
n=90
NT
n=95
DBI-I
n=61
CBT-I
n=60
NT
n=75
DBI-I
n=32
CBT-I
n=32
NT
n=46
Eating Pathology, M (SD)
9.05
(6.55)
9.8
(7.66)
10.39
(8.18)
6.97
(7.89)
5.32
(5.97)
8.96
(10.06)
10.43
(13.43)
7.53
(8.59)
8.13
(7.27)
Body Dissatisfaction, M (SD)
100.66
(28.43)
99.52
(27.03)
97.42
(33.28)
88.44
(32.58)
77.44
(27.31)
91.60
(31.72)
86.20
(34.33)
75.13
(29.56)
96.80
(32.32)
Thin-Ideal Internalization, M (SD)
24.19
(2.94)
23.30
(3.15)
23.54
(3.17)
20.85
(4.95)
21.37
(3.94)
23.22
(3.21)
21.40
(4.86)
22.22
(3.66)
23.60
(2.81)
Dieting, M (SD)
29.21
(6.18)
29.78
(7.54)
28.52
(7.48)
26.85
(7.78)
25.51
(7.17)
27.32
(7.45)
25.94
(7.21)
23.75
(8.36)
27.41
(7.70)
Depression, M (SD)
31.69
(8.47)
29.44
(7.57)
29.79
(7.49)
28.50
(6.86)
27.05
(7.50)
30.39
(8.83)
29.02
(7.57)
27.81
(8.26)
30.65
(9.38)
Note. DBI-I = internet dissonance-based intervention. CBT-I = internet cognitive-behavioral treatment. NT = no treatment. Means and standard deviations are
reported for completers of each assessment period.

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Table 2

Regression Results for Primary Study Outcomes
Outcome
Treatment
Comparison B SE B t d p
EAT DBI-I vs. CBT- -2.85 2.21 1.29 .25 .196
DBI-I vs. NT -2.02 2.02 -.99 .18 .318
CBT-I vs. NT -.84 2.09 -.40 .10 .699

BSQ DBI-I vs. CBT-I -6.04 6.17 -.97 .19 .328
DBI-I vs. NT -.12 .08 -1.59 .27 .110
CBT-I vs. NT -.20 .07 -2.58 .48 .010

IBSS DBI-I vs. CBT-I .88 .93 .95 .21 .342
DBI-I vs. NT -2.22 .84 -2.63 .56 .008
CBT-I vs. NT -1.33 .88 -1.51 .40 .131

DRES DBI-I vs. CBT-I -1.97 1.51 -1.30 .25 .193
DBI-I vs. NT -.086 .082 -1.06 .19 .291
CBT-I vs. NT .59 .06 9.71 .42 <.001

BDI DBI-I vs. CBT-I .05 .09 .588 .01 .56
DBI-I vs. NT -.12 .09 1.33 .01 18
CBT-I vs. NT -1.06 1.65 -.64 .01 .523
Note. DBI-I = internet dissonance-based intervention. CBT-I = internet cognitive-behavioral treatment. NT = no
treatment. EAT = Eating Attitudes Test. BSQ = Body Shape Questionnaire. IBSS = Ideal Body Stereotype Scale.
DRES = Dutch Restrained Eating Scale. BDI = Beck Depression Inventory. The DBI-I vs. CBT-I contrast variable
was dummy coded 0 = DBI-I, 1 = CBT-I. The DBI-I vs. NT contrast variable was dummy coded 0 = NT, 1 = DBI-I.
The CBT-I vs. NT condition contrast variable was dummy coded NT = 0, CBT-I = 1. Between-group effect sizes
(Cohen’s d) using adjusted means are presented.

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Table 3

Rates of Statistically Reliable Change by Condition

Statistically Reliable Change
n (%)

Study Outcome DBI-I
n =35
CBT-I
n = 32
NT
n = 47 χ
2
(2) p
EAT 3 (8.6) 0 (0.0) 1 (2.2) 3.89 .143
BSQ 1 (2.9) 0 (0.0) 0 (0.0) 2.22 .330
IBSS 4 (11.4) 2 (6.5) 1 (2.2) 2.94 .230
DRES 7 (20.0) 8 (25.8) 7 (15.2) 1.32 .517
BDI 6 (17.1) 4 (13.3) 10 (22.7) 1.10 .577
Note. DBI-I = internet dissonance-based intervention. CBT-I = internet cognitive-behavioral treatment. NT = no
treatment. EAT = Eating Attitudes Test. BSQ = Body Shape Questionnaire. IBSS = Ideal Body Stereotype Scale.
DRES = Dutch Restrained Eating Scale. BDI = Beck Depression Inventory. Reliable Change was calculated for
participants who completed the follow-up assessment.

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Figure Captions (Follow-up Assessment Completers)
Figure 1. Mean composite eating pathology by treatment condition
Figure 2. Mean body dissatisfaction by treatment condition
Figure 3. Mean thin-ideal internalization by treatment condition
Figure 4. Mean dieting by treatment condition
Figure 5. Mean depression by treatment condition

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Figure 1. Mean composite eating pathology by treatment condition.
Note. Observed means for T3 completers are presented.

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Figure 2. Mean body dissatisfaction by treatment condition.
Note. Observed means for T3 completers are presented.

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Figure 3. Mean thin-ideal internalization by treatment condition.
Note. Observed means for T3 completers are presented.

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Figure 4. Mean dieting by treatment condition.
Note. Observed means for T3 completers are presented.

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Figure 5. Mean depression by treatment condition.
Note. Observed means for T3 completers are presented.

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Appendix C:
DBI-I Session Content

DBI-I SESSION 1

The content of this session was derived from the protocol for the Body Project, an intervention
developed by Eric Stice, PhD., Heather Shaw, PhD., and Paul Rohde, PhD.

-----PAGE BREAK----- 

Thanks for coming to Go Figure! You decided to take part in this program because of your body
image concerns—a common issue among women/girls. Research shows that when women/girls
talk about the “beauty-ideal” shown in the mass media, and how to challenge pressures to be
thin, it makes them feel better about their bodies. Participants get the most out of the program
if they complete all four sessions, participate verbally by answering provided writing prompts,
and complete all of the between meeting exercises. It is important to clearly note that
participation is voluntary. Are you willing to volunteer to actively participate in today's
session?
 YES
 NO

-----PAGE BREAK----- 

Because you indicated that you do not wish to participate in today's session, you have been
logged out. You may exit the session by closing your browser window. Please contact the study
administrator at chithamb@usc.edu for instructions on how to re-enter the program.

-----PAGE BREAK----- 

You will complete four online sessions, each spaced approximately one week apart. You will
also be given between-session assignments. During the 4-week study period, a study
administrator will e-mail you the link to access your session on a weekly basis. You will log in to
the week's session using your school e-mail address and 5-digit password. Should you encounter
problems accessing session content, please e-mail the Principal Investigator, Taona Chithambo,
at chithamb@usc.edu.

During the four sessions I will: 1. Define the thin-ideal and explore its origin 2. Examine the
costs of pursuing this ideal 3. Explore ways to resist pressures to be thin 4. Discuss how to
challenge my personal body-related concerns 5. Learn new ways to talk more positively about
my bodies, and 6. Talk about how I can best respond to future pressures to be thin
-----PAGE BREAK----- 

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Please examine the images below:

What do these pictures say about my society's values regarding female appearance? Please write
your answer (2-4 sentences) in the text box below.
-----PAGE BREAK----- 

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What are I told the perfect woman looks like? Please provide 5 appearance-related qualities.

-----PAGE BREAK----- 

The "thin ideal"

I call this “look” – this thin, toned, busty woman – “the thin-ideal.” The thin-ideal is not the
same as the healthy-ideal. With the thin-ideal, people go to extreme measures to look ultra-thin
(like a super model), including some very unhealthy weight control behaviors and excessive
exercise. The goal of the thin-ideal is to attain thinness that is neither realistic or healthy. With
the healthy-ideal, the goal is health, fitness and longevity. A healthy body has both muscles and
adequate fat tissue. The healthy-ideal involves feeling good about how your body both feels and
works.

-----PAGE BREAK----- 

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-----PAGE BREAK----- 

Has this “thin-ideal” always been the ideal for feminine attractiveness? Has there ever been a
time in history when the “perfect woman” looked different? Please write 2-4 sentences.

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Where did the ideal come from? Who benefits from it? Please write 2-4 sentences.

-----PAGE BREAK----- 

Have you ever been the recipient of a negative comment about your weight or shape from your
friends, family, or dating partners? How did that make you feel? Please write 2-4 sentences.
-----PAGE BREAK----- 

How do thin-ideal messages from the media impact the way you view your body? Please write 2-
4 sentences.
-----PAGE BREAK----- 

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What does my culture tell us will happen if I are able to achieve the thin-ideal?

Do you really think these good things happen if you get thinner?

-----PAGE BREAK----- 

What are the costs of trying to look like the thin-ideal? Please name three physical or emotional
consequences of trying to achieve the thin-ideal.

Who benefits from the thin-ideal?

-----PAGE BREAK----- 

Nice work! What was it like to reflect on the impact of the thin ideal? Please write 2-4 sentences.

-----PAGE BREAK----- 

You have one between-session assignment to complete before next week's session. Please a write
one-page double-spaced letter to an adolescent girl who is struggling with body image concerns
about the costs associated with pursuing the thin ideal. You will e-mail this letter to the principal
investigator. Think of as many costs as you can. Feel free to work with a friend or family
member in generating ideas or use any of the ones discussed during your session. A study
administrator will e-mail you with detailed instructions on how to complete this assignment.

-----PAGE BREAK----- 

One more thing. . .on the next three pages you will find brief questionnaires about your reactions
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to today’s session. Then, you’re all done!

-----PAGE BREAK----- 

Thanks for your participation in this week's session, and again great work! See you next week!

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DBI-I SESSION 1 HOMEWORK ASSIGNMENT

Name:
USC e-mail address:
Student ID:
Session One Exercise:
Letter to Adolescent Girl

Please write a letter to an adolescent girl who is struggling with body image concerns about the costs
associated with pursuing the thin ideal. Think of as many costs as you can. Feel free to work with a
friend or family member in generating ideas or use any of the ones discussed during your session.
Please e-mail your letter to chithamb@usc.edu within one week of completing Go Figure! Session 1.

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DBI-I SESSION 2

The content of this session was derived from the protocol for the Body Project, an intervention
developed by Eric Stice, PhD., Heather Shaw, PhD., and Paul Rohde, PhD.

-----PAGE BREAK----- 

Thanks for returning to Go Figure! You decided to take part in this program because of your
body image concerns—a common issue among women/girls. Research shows that when
women/girls talk about the “beauty-ideal” shown in the mass media, and how to challenge
pressures to be thin, it makes them feel better about their bodies. Participants get the most out
of the program if they complete all four sessions, participate verbally by answering provided
writing prompts, and complete all of the between meeting exercises. It is important to clearly
note that participation is voluntary. Are you willing to volunteer to actively participate in today's
session?
 YES
 NO

-----PAGE BREAK----- 

*Only display if respondent indicates “NO” for the previous question*

Because you indicated that you do not wish to participate in today's session, you have been
logged out. You may exit the session by closing your browser window. Please contact the study
administrator at chithamb@usc.edu for instructions on how to re-enter the program.

-----PAGE BREAK----- 

Last week, you were asked to write a letter to an adolescent girl with body concerns. What was
that like for you? Did the exercise affect how you view your own body? Please write 4-10
sentences reflecting on this experience.

-----PAGE BREAK----- 

Last week I discussed the origin of the thin-ideal. The thin-ideal represents an unrealistic
standard for women's body thinness, and is often encmyaged by female images in the
media. Today, I will focus on thin-ideal statements. Below are examples of thin-ideal
statements commonly made by young women.
 "I have to be thin or my life is ruined."
 "I want to make sure I don't gain that freshman 15 this year, so I am only going to eat a
banana for breakfast and an apple for lunch every day."
 "No one will ever ask me out unless I lose 10 pounds."

-----PAGE BREAK----- 

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Many women make thin-ideal statements like the ones displayed on the previous page. Today,
you will work on thinking of comebacks for such statements.Below, you will find the same three
statements from the previous page, followed by comeback statements.

“I have to be thin or my life is ruined.”
COMEBACK: Being thin isn’t everything. There is more to you than just your weight.

“I want to make sure I don’t gain that freshman 15 this year, I am only going to eat a banana for
breakfast and an apple for lunch every day.”
COMEBACK: A banana and an apple are not enough to satisfy you. Starving yourself is not
good for you.

“No one will ever ask me out unless I lose 10 pounds.”
COMEBACK: You don’t have to be skinny to attract a partner. It’s best to be with someone
who likes you the way you are.

-----PAGE BREAK----- 

Now it’s your turn! You will be presented with more samples of thin-ideal statements. Please
provide a comeback for EACH statement. It’s okay if it is hard to come up with a good
comeback. Just do your best, and make sure to provide a comeback for each statement.

-----PAGE BREAK----- 

Also, if you need extra guidance for the first few questions, just click on the hint
button. However, you are still expected to write your own original comebacks. Hints are only
there to give you some ideas.

-----PAGE BREAK----- 

“I just saw an ad for this new weight loss pill, I’m going to order it right away. I can finally be as
thin as I want.”

Need a hint? Select the button below, then go to the next page for some ideas. Otherwise, just
fill in your response above, and click on the yellow forward button when you're done.
 Hint, please!

-----PAGE BREAK----- 

“Anyone could have the body of a supermodel if they really wanted it.”

Need a hint?Select the button below, then go to the next page for some ideas. Otherwise, just fill
in your response above, and click on the yellow forward button when you're done.
 Hint, please!

-----PAGE BREAK----- 
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“I am never going to be selected by a sorority unless I lose 10 pounds.”

Need a hint? Select the button below, then go to the next page for some ideas. Otherwise, just
fill in your response above, and click on the yellow forward button when you're done.
 Hint, please!

-----PAGE BREAK----- 

"Swimsuit season is just around the corner, so I am going to start skipping meals to lose weight."

-----PAGE BREAK----- 

“I feel a little dizzy lately, which may be from these diet pills I’m on, but I don’t care because I
have already lost 10 pounds.”

-----PAGE BREAK----- 

“Most people have weak will power and give in to hunger - I will show people how much self-
control I have by not eating anything but grapefruit.”

-----PAGE BREAK----- 

“I notice that Mary’s been gaining weight these past few weeks. She’s starting to look really
fat.”

-----PAGE BREAK----- 

“To be the best runner, I have to be down to my lightest weight. I am only doing this for my
health - this will help me avoid injuries.”

-----PAGE BREAK----- 

“My life would be perfect if I was 10 pounds lighter.”

-----PAGE BREAK----- 

“I’m too fat to be friends with such pretty girls.”

-----PAGE BREAK----- 

Awesome work this week! You have one assignment due before the next session. The
assignment: come up with verbal challenges for five examples of real-life thin-ideal situations or
statements you have experienced. For example, say your mom commented that another mom has
let herself go because she gained weight. Now, how could you you respond to this comment to
show you do not agree with the thin-ideal and think these sorts of comments are unhealthy? A
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verbal challenge to this statement might be "it seems rude to talk about someone’s weight when
you don’t know what is going on in their life", or "if you don't have anything nice to say, don't
say anything at all." Think of at least five situations from your real life, and potential verbal
challenges. The challenges probably won't be how you actually responded. Instead, they should
be how you would respond now that you know about the thin-ideal. You will receive an e-mail
with detailed instructions on how to complete this assignment.

One more thing. . .on the next three pages you will find brief questionnaires about your reactions
to today’s session. Then, you’re all done!

-----PAGE BREAK--- 

Thanks for your participation, and again great work! You will receive an e-mail with detailed
instructions on how to complete this week's between-session assignment. See you next week!

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Name:
USC e-mail address:
Student ID:

Session Two Exercise:
Verbal Challenge Form

Please provide at least 5 examples from your real life concerning pressures to be thin that you have
encountered and then come up with verbal challenges, like we did in the role-plays.

Here are some examples of thin-ideal statements:
1. A boyfriend might say that he thinks the ideal dress size is a 2.
2. Your mom might comment on how another mom has really let herself go because she
gained some weight.
3. A friend could say that she wished she looked like a particular supermodel when looking
over a fashion magazine.

How could you respond to these comments to indicate that you do not agree with the thin-ideal and
think these sorts of comments are unhealthy?

Please come up with at least five examples from your life. These examples probably won’t be how
you actually responded to the pressure. Instead, they should be how you might respond now based
on what you know about the thin-ideal. Please e-mail your completed assignment to
chithamb@usc.edu within one week of completing Go Figure! Session 2.

1) Situation:

Verbal Response:

2) Situation:

Verbal Response:

3) Situation:

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Verbal Response:

4) Situation:

Verbal Response:

5) Situation:

Verbal Response:

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DBI-I SESSION 3

The content of this session was derived from the protocol for the Body Project, an intervention
developed by Eric Stice, PhD., Heather Shaw, PhD., and Paul Rohde, PhD.

-----PAGE BREAK----- 

Welcome Back! Participants get the most out of the program if they complete all four
sessions, participate verbally by answering provided writing prompts, and complete all of the
between meeting exercises. It is important to clearly note that participation is voluntary. Are you
willing to volunteer to actively participate in today's session?
 YES
 NO

-----PAGE BREAK----- 
*Only display if respondent indicates “NO” for the previous question*

Because you indicated that you do not wish to participate in today's session, you have been
logged out. You may exit the session by closing your browser window. Please contact the study
administrator at chithamb@usc.edu for instructions on how to re-enter the program.

-----PAGE BREAK----- 

Last week, you were asked to to provide examples from your life of pressures to be thin and to
come up with how you might verbally challenge these pressures.What was that like for you? Did
the exercise affect how you view your own body? Please write 4-10 sentences reflecting on this
experience.

-----PAGE BREAK----- 

Last week I asked you to challenge thin-ideal statements in an extended role-play game. This
week I are going to do something a little different – I would like for you to briefly challenge
“thin-ideal” statements with a quick comeback. Your goal is simply to derail the fat talk. Below
you will find examples of thin-ideal statements, and brief comebacks.

“Does this shirt make my love handles too visible?”
COMEBACK: “I think it's best if I don’t ruminate about appearance issues like that.”

"I was thinking of getting a tummy tuck."
COMEBACK: "That's expensive and risky. You look fine the way you are."

"I am thinking of becoming vegan because I hear it helps you lose weight."
COMEBACK: "You should make diet decisions for your overall health, not just your
appearance."

-----PAGE BREAK----- 
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Again, you will be provided with examples of thin-ideal statements, and you will write a brief
comeback in the provided text boxes. It's okay if it's hard to come up with good comebacks
sometimes. Just do the best you can. Also, the hint button will be available for the first few
questions in case you would like some extra guidance. However, the hints are only there to give
you some ideas. It is your job to come up with your own original comebacks.

-----PAGE BREAK----- 

“Look at that fatso over there!”

Need a hint? Select the button below, then go the next page for some ideas. Otherwise, just fill
in your response above, and click on the yellow forward button when you're done.
 Hint, please!

-----PAGE BREAK----- 

“Lindsay has really gained weight over the holidays.”

Need a hint? Select the button below, then go the next page for some ideas. Otherwise, just fill
in your response above, and click on the yellow forward button when you're done.
 Hint, please!

-----PAGE BREAK----- 

“Lindsay has really gained weight over the holidays.”

-----PAGE BREAK----- 

“I’m thinking of going on a diet, do you want to join me?”

Need a hint? Select the button below, then go the next page for some ideas. Otherwise, just fill
in your response above, and click on the yellow forward button when you're done.
 Hint, please!

-----PAGE BREAK--- 

“Don’t you think that girl is a cow?”

-----PAGE BREAK--- 

“I would never be friends with someone that heavy.”

“My brother says I look too fat, what do you think?”

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“Don’t you think Jennifer Lopez is a little too heavy?”

“If I don’t lose some weight, I may be dropped from the diving team.”

-----PAGE BREAK--- 

“I really wish I had the body of a supermodel.”

“Only skinny girls get out asked by boys.”

“She really doesn’t have the body to be wearing that outfit.”

“I hate my body so much- I wish I could just wake up in a different one.”

-----PAGE BREAK--- 

Great work!How did it feel to make your comeback statements? Please write 2-4 sentences
reflecting on the experience.

Why might it be beneficial to challenge people when they make thin-ideal statements? Please
write three reasons.

-----PAGE BREAK--- 

Your homework exercise this week is to come up with a top-10 list of things girls/women can do
to resist the thin-ideal. So unlike the verbal challenge exercise, in which you challenge the thin-
ideal at the individual level, I are asking how you can challenge the thin-ideal at the societal
level. What can you avoid, say, do, or learn to battle this unhealthy beauty ideal in your
community? Please type up your top 10-list down and submit it to the principal investigator.
Examples: Write a letter to a fashion editor stating that more body types should be featured in
their magazine. Write a letter to a company indicating that you are boycotting their product
because they promote the thin-ideal in their ads. Stop subscribing to a fashion magazine. Put
post-its on mirrors in women's bathrooms saying "love your body". You will receive an e-mail
with detailed instructions on how to complete this assignment.

-----PAGE BREAK--- 

One more thing. . .on the next three pages you will find three brief questionnaires about your
reactions to today’s session. Then, you’re all done!

-----PAGE BREAK--- 

Thanks for your participation, and again great work! You will receive an e-mail with detailed
instructions on how to complete this week's between-session assignment. See you next week!

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DBI-I SESSION 3 HOMEWORK ASSIGNMENT
Name:
USC e-mail address:
Student ID:

Session Three Exercise:
Top-10 List Form
Please generate a top-10 list of things girls/women can do to resist the thin-ideal. What can you
avoid, say, do, or learn to battle this beauty ideal? Please e-mail your completed assignment to
chithamb@usc.edu within one week of completing Go Figure! Session 3.

Examples
 Write letter to fashion magazine editor saying they should include a variety of body sizes in
the magazine.
 Write a letter to a company indicating that you are boycotting their product because they
promote the thin-ideal in their ads..
 Put post-its on mirrors in women’s bathrooms saying “love your body”.
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
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DBI-I Session 4

The content of this session was derived from the protocol for the Body Project, an intervention
developed by Eric Stice, PhD., Heather Shaw, PhD., and Paul Rohde, PhD.

-----PAGE BREAK----- 

Welcome Back! Participants get the most out of the program if they complete all four
sessions, participate verbally by answering provided writing prompts, and complete all of the
between meeting exercises. It is important to clearly note that participation is voluntary. Are you
willing to volunteer to actively participate in today's session?
 YES
 NO

-----PAGE BREAK----- 
*Only display if respondent indicates “NO” for the previous question*

Because you indicated that you do not wish to participate in today's session, you have been
logged out. You may exit the session by closing your browser window. Please contact the study
administrator at chithamb@usc.edu for instructions on how to re-enter the program.

-----PAGE BREAK----- 

Last week, you were asked to come up with a list of 10 things that girls/women could do to resist
the thin ideal- what you can avoid, say, do, or learn to fight this social pressure. Please write 4-
10 sentences reflecting on this experience.

-----PAGE BREAK----- 

I’ve spent a lot of time discussing obvious pressures to be thin that I encounter on a regular basis
from the media, friends, and family members. However, I often do not notice some of the more
subtle ways the the thin-ideal keeps going. For example:
 Talking about weight loss diets
 Complimenting others on weight loss
 Joining in when friends complain about their bodies

-----PAGE BREAK----- 

What can you say to stop this sort of talk? Or, how can you change the subject?

How do you think changing the way you talk about your body might impact how you feel about
your body, and how others respond to you?

-----PAGE BREAK----- 

Today, you will practice challenging fat talk. Respond in a way that signals you do not approve
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of the pro-thin-ideal statement. Below, you will find sample comebacks to fat talk.

"Can you believe how much she's let herself go?"
COMEBACK: I shouldn't be talking about someone else's weight. I don't know what's been
going on in her life lately.

"I've really been doing well on this diet, you should try it. . ."
COMEBACK: "I don't agree with dieting to become thinner.

Your turn! Please enter your own responses to the fat talk statements. It's okay if it's hard to
come up with good responses sometimes. Just do the best you can.And remember, if you get
stuck, for the first few questions you can click on the hint button for help. However, the hints are
only there to give you some ideas. It is your job to come up with your own original comebacks.
-----PAGE BREAK----- 

"You think you're fat? Look at me!"

Need a hint? Select the button below, then go to the next page for some ideas. Otherwise, just
fill in your response above, and click on the yellow forward button when you're done.
 Hint, please!

-----PAGE BREAK----- 

“Gee, you look great. Have you lost weight?”

Need a hint? Select the button below, then go to the next page for some ideas. Otherwise, just
fill in your response above, and click on the yellow forward button when you're done.
 Hint, please!

-----PAGE BREAK----- 

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“I can’t eat that- it will make me fat.”

Need a hint? Select the button below, then go to the next page for some ideas. Otherwise, just
fill in your response above, and click on the yellow forward button when you're done.
 Hint, please!

-----PAGE BREAK----- 

“I’m way too fat to be eating this.”

-----PAGE BREAK----- 

“I’m too fat to get into a bathing suit.”

“She’s too fat to be wearing those pants.”

“She’s a little bit heavy to be dating that guy.”

“You’re so thin, how do you do it?”

-----PAGE BREAK----- 

Great work! How did it feel to make your comeback statements? Please write 2-4 sentences
reflecting on the experience.

Why might it be beneficial to challenge fat talk? Please write three reasons.

-----PAGE BREAK----- 

Your between-session assignment is to submit another letter to an adolescent girl. Use what you
have learned during the past four sessions about the thin ideal, fat talk, and comeback statements
to teach her about the pitfalls of unrealistic body standards and how to overcome them.You will
receive a detailed e-mail from the study administrator with detailed instructions on how to
complete this assignment.

-----PAGE BREAK----- 

One more thing. . .on the next three pages you will find three brief questionnaires about your
reactions to today's session. Then, you're all done!

-----PAGE BREAK--- 

Thanks for your participation, and again great work! You will receive an e-mail with detailed
instructions on how to complete this week's between-session assignment. See you next week!

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DBI-I SESSION 4 HOMEWORK ASSIGNMENT

Name:
USC e-mail address:
Student ID:

Session Four:
Letter to Adolescent Girl

Please write another one-page letter to an adolescent girl telling her how to avoid developing body
image concerns. Use any of the information you have learned in these sessions, and any additional
ways you may think of on your own. The goal is to help her understand the different things she can
do, say, avoid, or learn that will help her develop or maintain a positive body image. Please e-mail
your completed assignment to chithamb@usc.edu within one week of completing Go Figure!
Session 4.

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Appendix D:
CBT-I Session Content

CBT-I Session 1

The content of this session was derived from the The Body Image Workbook: An 8-Step
Program for Learning to Like Your Looks by Thomas Cash, PhD.

-----PAGE BREAK----- 

Thanks for coming to Go Figure! You decided to take part in this program because of your body
image concerns—a common issue among women/girls. Research shows that when women/girls
talk about their body image problems, and how to challenge self-critical thoughts, it makes them
feel better about their bodies.

Participants get the most out of the program if they complete all four sessions, participate
verbally by answering provided writing prompts, and complete all of the between meeting
exercises. It is important to clearly note that participation is voluntary. Are you willing to
volunteer to actively participate in today's session?
 YES
 NO

-----PAGE BREAK----- 

*Only display if respondent indicates “NO” for the previous question*

Because you indicated that you do not wish to participate in today's session, you have been
logged out. You may exit the session by closing your browser window. Please contact the study
administrator at chithamb@usc.edu for instructions on how to re-enter the program.

-----PAGE BREAK----- 

You will complete four online sessions, each spaced approximately one week apart. You will
also be given between-session assignments. During the 4-week study period, a study
administrator will e-mail you the link to access your session on a weekly basis. You will log in to
the week's session using your school email address and 5-digit password. Should you encounter
problems accessing session content, please e-mail the Principal Investigator, Taona Chithambo,
at chithamb@usc.edu.

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During the four sessions I will: 1. Define body dissatisfaction and explore where it comes
from 2. Examine the costs of body image problems 3. Explore ways to improve body image and
disrupt maladaptive eating patterns 4. Discuss how to challenge negative thoughts about my
bodies 5. Learn new ways to think more positively about my bodies, and6. Talk about how I can
best respond to future pressures to be thin

-----PAGE BREAK----- 

Please examine the image below:

What does this chart say about gender differences in body dissatisfaction? Please write your
answer (2-4 sentences) in the text box below.

-----PAGE BREAK----- 

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What are some of the most commonly disliked physical traits? Please name 5 appearance-related
qualities.

-----PAGE BREAK----- 

Consequences of Negative Body Image

Most people dislike something about their looks. However, ongoing body image problems can
cause other problems in living. A poor body image often lowers self-esteem. A negative body
image can also cause interpersonal anxiety; if you can’t accept your looks, you most likely
assume others don’t like your looks either. A negative body image can bring about eating
disturbances, such as anorexia nervosa or bulimia nervosa. Also, depression and body image are
often intertwined.

-----PAGE BREAK----- 

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Please examine the chart below:

-----PAGE BREAK----- 

Is the frequency of body image problems among women changing over time? Has there ever
been a time in history when fewer women had body image issues? Please write 2-4 sentences.

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Are there cultural differences in preferences for female body weight or shape? What kinds of
differences are there? Please write 2-4 sentences.

What body traits are valued in modern American culture? Please write 2-4 sentences.

-----PAGE BREAK----- 

Have you ever felt self-conscious about your own body? How did that make you feel? Please
write 2-4 sentences.

-----PAGE BREAK----- 

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How do young people learn about cultural body image norms?

How might body ideals from childhood affect adult body image?

What are some consequences of rigid body image standards? Please name three physical or
emotional consequences of poor body image.

What are the benefits of having a positive body image?
-----PAGE BREAK----- 

Nice work! What was it like to reflect on the origins of body image? Please write 2-4 sentences.

-----PAGE BREAK----- 

You have one between-session assignment to complete before next week's session. Please a write
one-page double-spaced letter that summarizes what you learned from today's session. You will
be sent a link to submit this letter electronically to the principal investigator.Think of as much
information as you can. Feel free to work with a friend or family member in generating ideas or
use any of the ones discussed during your session. A study administrator will e-mail you with
detailed instructions on how to complete this assignment.

One more thing. . .on the next three pages you will find brief questionnaires about your reactions
to today’s session. Then, you’re all done!

-----PAGE BREAK----- 

Thanks for your participation in this week's session, and again great work!

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CBT-I SESSION 1 HOMEWORK ASSIGNMENT
Name:
USC e-mail address:
Student ID:
Session One Exercise:
Session Summary Letter

Please a write one page double-spaced letter that summarizes what you learned from Session 1.
Think of as much information as you can. Feel free to work with a friend or family member in
generating ideas or use any of the ones discussed during your session. Please e-mail your letter to
chithamb@usc.edu within one week of completing Go Figure! Session 1.

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CBT-I SESSION 2

The content of this session was derived from the The Body Image Workbook: An 8-Step
Program for Learning to Like Your Looks by Thomas Cash, PhD.
-----PAGE BREAK----- 

Thanks for returning to Go Figure! You decided to take part in this program because of your
body image concerns—a common issue among women/girls. Research shows that when
women/girls talk about their body image problems, and how to challenge self-critical thoughts, it
makes them feel better about their bodies. Participants get the most out of the program if they
complete all four sessions, participate verbally by answering the provided writing prompts, and
complete all of the between meeting exercises. It is important to clearly note that participation is
voluntary. Are you willing to volunteer to actively participate in today's session?
 YES
 NO

-----PAGE BREAK----- 

*Only display if respondent indicates “NO” for the previous question*

Because you indicated that you do not wish to participate in today's session, you have been
logged out. You may exit the session by closing your browser window. Please contact the study
administrator at chithamb@usc.edu for instructions on how to re-enter the program.

-----PAGE BREAK----- 

Last week, you were asked to write a letter to summarizing what you learned in the first session.
What was that like for you? Did the exercise affect how you view your own body? Please write
4-10 sentences reflecting on this experience.

-----PAGE BREAK----- 

Last week I discussed the societal underpinnings of female body image. Today, I will focus on
appearance assumptions that direct how you think about your own physical
characteristics. Appearance assumptions are your core beliefs about the relevance and influences
of your looks in your life. Below are examples of appearance assumptions commonly made by
young women. " If I get to my desired appearance, my life will be perfect." " Physical flaws
are not acceptable." " People pay close attention to how I look in most situations."

Many women hold assumptions like the ones displayed on the previous page. Today, you will
learn to argue against these assumptions using your new inner voice. This voice speaks in ways
that are understanding, tolerant, fair, realistic, logical and assured. Below, you will find the same
three assumptions from the previous page, followed by examples of how your new, rational inner
voice would challenge them.

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"If I get to my desired appearance, my life will be perfect."
CHALLENGE: Looking perfect does not guarantee a perfect life. It's not reasonable to place so
much importance on my appearance.

"Physical flaws are not acceptable."
CHALLENGE: Everyone has flaws. My flaws don't take away from my other qualities. I should
work on accepting myself the way I am.

"People pay close attention to how I look in most situations."
CHALLENGE: No one pays as much attention to my looks as I do. Most of the time, people are
in their own world and worried about their own problems.

-----PAGE BREAK----- 

Now it’s your turn! You will be presented with common body image assumptions. Please
come up with a few sentences that challenge EACH assumption. It’s okay if it is hard to come up
with good challenges. Just do your best, and make sure to provide a challenge for each statement.

Also, if you need extra guidance for the first few questions, just click on the hint
button. However, you are still expected to write your own original challenges. Hints are only
there to give you some ideas.

-----PAGE BREAK----- 

“Physically attractive people have it all.”

Write your challenge to this statement here.

Need a hint? Select the button below, then go to the next page for some ideas. Otherwise, just
fill in your response above, and click on the yellow forward button when you're done.
 Hint, please!

-----PAGE BREAK----- 
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“The only thing people notice about me is my appearance.”

Write your challenge to this statement here.

Need a hint? Select the button below. Otherwise, just click the yellow arrow button at the
bottom right corner of the page.
 Hint, please!

-----PAGE BREAK----- 

“I could look just as I wish, my life would be much happier.”

Write your challenge to this statement here.

Need a hint? Select the button below. Otherwise, just click the yellow arrow button at the
bottom right corner of the page.
 Hint, please!

-----PAGE BREAK----- 

“If I could just look as I wish, my life would be much happier.”

Write your challenge to this statement here.

-----PAGE BREAK----- 

“If people knew how I really look, they would like me less.”

Write your challenge to this statement here.

-----PAGE BREAK----- 

"By controlling my appearance, I can control my social and emotional life."

Write your challenge to this statement here.

-----PAGE BREAK----- 

"My appearance is responsible for much of what has happened to me in life."

Write your challenge to this statement here.

-----PAGE BREAK----- 

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"I should always do whatever I can to look my best."

Write your challenge to this statement here.

-----PAGE BREAK----- 

"The media's messages make it impossible for me to be satisfied with my appearance."

Write your challenge to this statement here.

-----PAGE BREAK----- 

"One's outward appearance is a sign of the inner person."

Write your challenge to this statement here.

-----PAGE BREAK----- 

"The only way I can ever like my looks would be to change them."

Write your challenge to this statement here.

-----PAGE BREAK----- 

Awesome work this week! You have one between-session assignment due before the next
session. The assignment: Come up with five examples of appearance assumptions from your
own life. For example, say that you used to think you needed to look perfect at all times. Now,
how would your new inner voice respond to let you know that this unhealthy? It might say, “it is
unreasonable to expect to look perfect at all times”, or “I don’t need to look perfect all the time
to feel good about myself”. Think of at least five assumptions from your real life, and potential
challenges. It is okay if your ideas are influenced by what you practiced during the session
today. The important thing is that you respond to your past appearance assumption with your
new inner voice. You will receive an e-mail detailing how to submit this assignment to the
principal investigator.

-----PAGE BREAK--- 

Thanks for your participation, and again great work! See you next week!

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CBT-I SESSION 2 HOMEWORK ASSIGNMENT

Name:
USC e-mail address:
Student ID:

Session Two Exercise:
Verbal Challenge Form

Please provide at least 5 examples of appearance assumptions from your real life and then come up
with verbal challenges, like we did in the role-plays.

Here are some examples of appearance assumptions:
1. I need to look perfect at all times.
2. My life would be easier if I lost weight.
3. My appearance is the reason for all of the bad things that happen to me.

How would your new inner voice respond to let you know that these assumptions are unhealthy?
For example, say that you used to think you needed to look perfect at all times. Now, how would
your new inner voice respond to let you know that this unhealthy? It might say, “It’s unreasonable
to expect to look perfect at all times”, or “I don’t need to look perfect all the time to feel good about
myself”.

Please come up with at least five examples from your life. Your challenges may not reflect how you
have thought about these assumptions in the past. Instead, they should be how you might respond
now based on what your new, rational inner voice would say. Please e-mail your completed
assignment to chithamb@usc.edu within one week of completing Go Figure! Session 2.

1) Appearance Assumption:

Challenge:

2) Appearance Assumption:

Challenge:

3) Appearance Assumption:
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Challenge:

4) Appearance Assumption:

Challenge:

5) Appearance Assumption:

Challenge:

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CBT-I SESSION 3

The content of this session was derived from the The Body Image Workbook: An 8-Step
Program for Learning to Like Your Looks by Thomas Cash, PhD.

-----PAGE BREAK----- 

Welcome Back! Participants get the most out of the program if they complete all four
sessions, participate verbally by answering the provided writing prompts, and complete all of the
between meeting exercises. It is important to clearly note that participation is voluntary. Are you
willing to volunteer to actively participate in today's session?
 YES
 NO

-----PAGE BREAK----- 
*Only display if respondent indicates “NO” for the previous question*

Because you indicated that you do not wish to participate in today's session, you have been
logged out. You may exit the session by closing your browser window. Please contact the study
administrator at chithamb@usc.edu for instructions on how to re-enter the program.

-----PAGE BREAK----- 

Last week, you were asked to to provide examples of appearance assumptions from your own
life, and how your rational inner voice would challenge those assumptions.What was that like for
you? Did the exercise affect how you view your own body? Please write 4-10 sentences
reflecting on this experience.

-----PAGE BREAK----- 

Last week I asked you to practice challenging your appearance assumptions. This week I are
doing to do something a little different – I would like for you to work on correcting your private
body talk. Your goal is to use your rational inner voice to challenge thoughts you have about
your own body. Below you will find examples of private body talk, and examples of how your
rational inner voice might respond.

"As long as I look the way I do, no one will ever fall in love with me."
RATIONAL INNER VOICE: I want someone to fall in love with me for who I am, not just how
I look.

"I’m not as good-looking as a fashion model."
RATIONAL INNER VOICE: There is no need to compare my looks to a fashion model or
anyone else. I should accept myself for how I am.

“ I’m too fat, so I can’t eat in front of other people.”
RATIONAL INNER VOICE: I need food regardless of what I look like. I shouldn't avoid eating
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because of my insecurities.

Again, you will be provided with examples of negative body talk, and you will write a challenge
that accesses your new inner voice in the provided text boxes. It's okay if it's hard to come up
with good challenges sometimes. Just do the best you can. Also, the hint button will be
available for the first few questions in case you would like some extra guidance. However, the
hints are only there to give you some ideas. It is your job to come up with your own original
challenge statements.

-----PAGE BREAK----- 

“Either I’m the perfect weight or I’m fat.”

Need a hint?S Select the button below, then go to the next page for some ideas. Otherwise, just
fill in your response above, and click on the yellow forward button when you're done.
 Hint, please!

-----PAGE BREAK----- 

“The best way to figure out how attractive I am is to compare myself to others.”

Need a hint?Select the button below, then go to the next page for some ideas. Otherwise, just fill
in your response above, and click on the yellow forward button when you're done.
 Hint, please!

"The best way to figure out how attractive I am is to compare myself to others." Sample
challenge statements: Comparing myself to other people will only make me more obsessed
with my appearance. I don't

-----PAGE BREAK----- 
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“It makes sense to focus more on my flaws than any of my other physical assets.”

Need a hint? Select the button below, then go to the next page for some ideas. Otherwise, just
fill in your response above, and click on the yellow forward button when you're done.
 Hint, please!

-----PAGE BREAK----- 

“My looks are the reason for all of the bad things that have happened to me.”

Need a hint?Select the button below, then go to the next page for some ideas. Otherwise, just fill
in your response above, and click on the yellow forward button when you're done.
 Hint, please!

-----PAGE BREAK----- 

"I am much less attractive than everyone else."

-----PAGE BREAK----- 

“Because of how I look, I’ll never get ahead in life.”

“I shouldn’t spend time with others until I lose some weight.”

“I feel unattractive, so obviously I am unattractive.”

“I ought to have a smaller waist.”

-----PAGE BREAK----- 

“Until I lose these few pounds, I look really fat.”

“I wish I had the body of a supermodel.”

"If I looked differently, I would have more friends."

"With my body, I'll never have a boyfriend."

-----PAGE BREAK----- 

Great work!How did it feel to challenge your private body talk? Please write 2-4 sentences
reflecting on the experience.

Why might it be beneficial to challenge your private body talk? Please write three reasons.

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-----PAGE BREAK----- 

Your between-session assignment this week is to come up with a list of 10 benefits that you
might gain from changing the way you think about your body. I know that thinking negatively
about your body tends to result in poor body image. What are some good things that might come
from using your new inner voice? Please type up your list and submit it to the principal
investigator. Examples: Less time spent trying to look perfect in the mornings. Can go out to
eat without worrying so much about what others think of my weight. Improved self
esteem. You will receive an e-mail with detailed instructions on how to submit this
assignment to the principal investigator.

One more thing. . .on the next three pages you will find brief questionnaires about your reactions
to today’s session. Then, you’re all done!

-----PAGE BREAK----- 

Thanks for your participation, and again great work! See you next week!

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CBT-I SESSION 3 HOMEWORK ASSIGNMENT
Name:
USC e-mail address:
Student ID:

Session Three Exercise:
Top-10 List Form

Your assignment this week is to come up with a list of 10 benefits that you might gain from
changing the way you think about your body. We know that thinking negatively about your body
tends to result in poor body image. What are some good things that might come from using your
New Inner Voice? Please e-mail your completed assignment to chithamb@usc.edu within one week
of completing Go Figure! Session 3.
Examples:
 Less time spent trying to look perfect in the mornings.
 Can go out to eat without worrying so much about what others think of my weight.
 Improved self-esteem.
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
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CBT-I SESSION 4

The content of this session was derived from the The Body Image Workbook: An 8-Step
Program for Learning to Like Your Looks by Thomas Cash, PhD.

-----PAGE BREAK----- 

Welcome Back! Participants get the most out of the program if they complete all four
sessions, participate verbally by answering provided writing prompts, and complete all of the
between meeting exercises. It is important to clearly note that participation is voluntary. Are you
willing to volunteer to actively participate in today's session?
 YES
 NO

-----PAGE BREAK----- 

*Only display if respondent indicates “NO” for the previous question*

Because you indicated that you do not wish to participate in today's session, you have been
logged out. You may exit the session by closing your browser window. Please contact the study
administrator at chithamb@usc.edu for instructions on how to re-enter the program.

-----PAGE BREAK----- 

Last week, you were asked to come up with a list of 10 positive outcomes of changing your
private body talk. What was that like for you? Did the exercise affect how you view your own
body? Please write 4-10 sentences reflecting on this experience.

-----PAGE BREAK----- 

I’ve spent a lot of time discussing how your own self talk affects your body image. You might
sometimes find that friends, loved ones, or acquaintances make insensitive remarks that stir up
your body image distress.
For example:
 Suggesting changes to your appearance
 Teasing you about your weight or other physical characteristics
 Comparing your looks to others

-----PAGE BREAK----- 

How do you feel when others make insensitive comments about your appearance?

How do you usually respond when others make insensitive comments about your appearance?

-----PAGE BREAK----- 

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Today, you will practice making brief, rational responses to insensitive remarks made by others.
It often helps to specifically state how what the person said makes you feel, or to make a specific
request for what you would like the person to do differently. Below, you will find sample
responses to insensitive remarks.

"Those shorts are a little tight on you."
RESPONSE: Please don't comment on my clothes unless I ask you.

"I only tease you about your pimples because I love you."
RESPONSE: "My pimples are a part of me, it makes me uncomfortable when you tease me
about them".

-----PAGE BREAK----- 

Your turn! Please enter your own responses to the insensitive remarks. It's okay if it's hard to
come up with good responses sometimes. Just do the best you can.And remember, if you get
stuck, for the first few questions you can click on the hint button for help. However, the hints are
only there to give you some ideas. It is your job to come up with your own original comebacks.
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-----PAGE BREAK----- 

“I thought your legs looked better when you were taking ballet.”
"
Need a hint?Select the button below, then go to the next page for some ideas. Otherwise, just fill
in your response above, and click on the yellow forward button when you're done.
 Hint, please!
-----PAGE BREAK----- 

“Wow, you’re a bit chubby these days!”

Need a hint?Select the button below, then go to the next page for some ideas. Otherwise, just fill
in your response above, and click on the yellow forward button when you're done.
 Hint, please!

-----PAGE BREAK----- 
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"Are you really going to get seconds? You've had so much to eat already!"

Need a hint? Select the button below, then go to the next page for some ideas. Otherwise, just
fill in your response above, and click on the yellow forward button when you're done.
 Hint, please!
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-----PAGE BREAK----- 

“That dress isn’t right for your figure.”

-----PAGE BREAK----- 

“Maybe you should try going on the Atkins Diet.”

"Your hips are definitely wider than they used to be."

"Dating might be easier if you just lost a few more pounds."

“Have you stopped going to the gym? You’re looking a little soft.”

-----PAGE BREAK----- 

Great work!How did it feel to respond to these statements? Please write 2-4 sentences reflecting
on the experience.

Why might it be beneficial to challenge insensitive body remarks? Please write three reasons.

-----PAGE BREAK----- 

Your final assignment is to submit another letter to the principal investigator summarizing what
you have learned while participating in Go Figure. Use what you have learned during the past
four sessions about where body image problems come from, appearance assumptions, body
image distortions, and challenging the insensitive remarks of others. You will receive a detailed
e-mail from the study administrator with instructions on how to complete this assignment.One
more thing. . .on the next three pages you will find brief questionnaires about your reactions to
today’s session. Then, you’re all done!

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CBT-I SESSION 4 HOMEWORK ASSIGNMENT

Name:
USC e-mail address:
Student ID:

Session Four Exercise:
Session Summary Letter

Please write another letter summarizing what you have learned from participating in Go Figure. Use
what you have learned during the past four sessions about where body image problems come from,
appearance assumptions, body image distortions, and challenging the insensitive remarks of others.
Please e-mail your completed assignment to chithamb@usc.edu within one week of completing Go
Figure! Session
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Appendix E:
Author-Developed Assessment Measures

Body Thoughts Questionnaire

The following statements describe thoughts about body appearance. In this moment, how
strongly do you agree with each statement?
Strongly agree Agree Neither Agree
nor Disagree
Disagree Strongly
Disagree
My body
needs more
muscle
definition
    
I'm
comfortable
with my
appearance
    
I hate my
body
    
I like the way
I look
    
I'm at least as
attractive as
most people
    
I'm not
attractive
    
My body has
good
proportions
    
I can't stand
my
appearance
    
I'm proud of
my body
    
I'm
disappointed
in my
appearance
    

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Dissonance Proxy Scale

The following statements describe reactions one might have to completing the activities of
today’s session. For each statement, please choose the option that best describes what you think
or feel in this moment.

Strongly
Agree
Agree Neither Agree
nor Disagree
Disagree Strongly
Disagree
I am in
despair
    
I feel
resentful
    
I am
disappointed
with myself
    
I feel scared     
I feel hollow     
I feel angry     
I feel uneasy     
I feel that I've
let myself
down
    
I feel
annoyed
    
I feel
frustrated
    
I am in pain     
I feel
depressed
    
I feel furious
with myself
    
I feel sick     
I am in agony     
I wonder
whether I
need to
pursue a thin
body type
    
I wonder if i
should try to
change my
body at all
    

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Strongly
Agree
Agree Neither Agree
nor Disagree
Disagree Strongly
Disagree
I wonder if
becoming
more thin is
right for me
    
I wonder if I
have done
the right thing
in challenging
beliefs about
my body
    
I wonder if I
am being
fooled
    
I wonder if I
have been
given false
information
    
I wonder if
there is
something
wrong with
the
information
that was
presented
    

Abstract (if available)

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Asset Metadata

Creator Chithambo, Taona Patricia (author)

Core Title Internet-delivered eating disorder prevention: a randomized controlled trial of dissonance-based and cognitive-behavioral treatments

School College of Letters, Arts and Sciences

Degree Doctor of Philosophy

Degree Program Psychology

Publication Date 08/03/2016

Defense Date 05/04/2015

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag cognitive-behavioral therapy,dissonance-based intervention,eating disorder prevention,Internet,mediators,OAI-PMH Harvest,randomized controlled trial

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Huey, Stanley (committee chair), Gatz, Margaret (committee member), McLaughlin, Peggy (committee member), Schwartz, David (committee member), Wood, Wendy (committee member)

Creator Email chithamb@usc.edu,tchithambo@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-295128

Unique identifier UC11281186

Identifier etd-ChithamboT-4727.pdf (filename),usctheses-c40-295128 (legacy record id)

Legacy Identifier etd-ChithamboT-4727.pdf

Dmrecord 295128

Document Type Dissertation

Format application/pdf (imt)

Rights Chithambo, Taona Patricia

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA