Sometimes when we discuss the problem of negative body image in eating disorders, it sounds like some magic mirror exists that enables people to see themselves differently. While we might wish that were true, in reality changing one’s body image requires constant commitment to a series of small, but powerful steps.

First, the therapist will work with the individual to get a sense of where the negative self-image originated, asking how long the patient has had it or if she remembers when it started. That can help the patient increase awareness of the original messages that led to the poor self-image.

Often people with eating disorders have internalized the messages of a loved one, or person of trust, to the extent that it may profoundly affect the patient’s sense of self-worth. For many people, those early message become part of their negative self-talk or “tape” in their head, which they never challenge and never consciously “hear.”

Once the patient has become aware of their negative self-talk, the therapist prompts them to notice when they say it. How often does it come up? What situations make the self-criticism more likely? This step makes the patient mindful of something that was happening automatically.

Looking at the triggers and at the messages enables the patient to recognize the cognitive distortions involved. The therapist helps them understand the arbitrary nature of the original message and the internal tape. Perhaps a patient’s mental recording replays a comment from a teacher or mean girls at school. Understanding that it could as easily have been a different, more positive message, such as her mother saying she is beautiful just the way she is takes away some of the power, the artificial “truth” of the selected message. In other words, the message is only true if you believe it.

Sometimes people have a hard time giving up their negative messages; they are really invested in believing them. One effective technique for getting them to challenge those tapes are to have them imagine that their child or best friend was looking in the mirror and saying the same words. Most would immediately tell someone else, “Your shape does not define you. You are more than your body.” That makes them more aware that they should not talk to themselves so negatively either, knowing they would never use such cruel language when describing a friend.

When the patient knows that the tape she plays internally could have been something—anything—else, she has the freedom to replace it with a more positive message. Initially, she may find it hard to believe another message. Even a soft message such as “I accept myself as I am” might seem silly or unnatural. At some level, we know these messages are just words, but the words evoke emotion and those emotion lead to actions. The right messages cause a beneficial cascade.

The key to internalizing new messages rests with repetition. The old, negative messages have run unquestioned for years. The new ones will take more than a few tries to gain a foothold. Saying them when doing a daily activity, like brushing teeth, for instance, ensures that the patient regularly repeats the positive message. The association will become more automatic over time, so that the affirmation becomes one of the first thoughts of the day and the last thought at night.

Because the mind focuses on what stays most in the forefront, a positive start can color the whole day and bring forth a more positive sense of self. That’s not to say that negative thoughts will not intrude. They will. But with support, someone with an eating disorder can bring awareness to those thoughts, write them down and explicitly replace them with something more affirming.

The final step involves metaprocessing, which makes individuals more mindful of how they treat themselves. It’s a bit of a daily debriefing: How well did I adhere to my program today? Did I take a moment to be aware of my choices? Was I kind? Was I authentic? What did I do well?

The entire process is one of change and acceptance, with the goal that patients will come to accept and love themselves and their bodies, even as they strive to change and grow.