A narrative review on clinical and research applications of The Mirror Paradigm: body image, psychopathology, and attachment

Stefania Muzi, Francesco Madera, Anthony Boiardo


The Mirror Paradigm (MP) is an innovative technique that explores the influences of body representation, affect regulation, and nonverbal mirror behavior in children, adolescents and adults. The critical element of the MP is the use of a full-length mirror in front of which the interviewee is asked to answer questions about how they think and feel about their body, including perception, parental and sociocultural influences and the mind-body connection. Though research on MP is limited and focused mainly on adults, its many advantages are recognized. This narrative review aims to summarize its broad applicability, strengths and weakness and potential uses in both research and clinical settings.

The review of the literature was performed through a research on PsycArticles, PsycInfo, Psychology & Behavioral Sciences Collection, PubMed and Web of Science Scopus databases, plus Google Scholar and ResearchGate, including pertinent and providing quantitative or qualitative data documents. Of 505 documents, 7 articles were eligible for this review (1.4% of initial records).

Results revealed  three main application of the MP: 1) Body image, where MP scores have been significantly correlated to body dissatisfaction assessed through questionnaires; 2) Psychopathology, where MP scores were useful in discriminating individuals with personality disorders and internalizing, externalizing, dissociative, and disordered eating symptoms; 3) Attachment, with nonverbal expressions and narratives about relationships to important others distinguishable between secure, preoccupied, and dismissive speakers as classified in the Adult Attachment Interview. Limitations and future directions are discussed, suggesting the MP as an innovative technique and measure promising for further integration in research and clinical practice.


Mirror Paradigm, Body image, Psychopathology, Attachment.

Full Text:



Achenbach, T. M., Dumenci, L., & Rescorla, L. A. (2001). Ratings of relations between DSM-IV diagnostic categories and items of the CBCL/6-18, TRF, and YSR. Burlington, VT: University of Vermont, 1-9. Retrieved from: http://citeseerx.ist.psu.edu/viewdoc/download?doi=

Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Lawrence Erlbaum.

Akhtar, S., & Samuel, S. (1996). The concept of identity: developmental origins, phenomenology, clinical relevance, and measurement. Harvard review of psychiatry, 3(5), 254-267. https://doi.org/10.3109/10673229609017193

Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical psychology review, 30(2), 217-237. https://doi.org/10.1016/j.cpr.2009.11.004

Amianto, F., Martini, M., Spalatro, A., Abbate, D. F., & Fassino, S. (2017). Body image development within the family: Attachment dynamics and parental attitudes in cross-sectional and longitudinal studies. Acta Psychopathol, 3(4), 50. https://doi.org/10.4172/2469-6676.100122

Barnes, M., Abhyankar, P., Dimova, E., & Best, C. (2020). Associations between body dissatisfaction and self-reported anxiety and depression in otherwise healthy men: A systematic review and meta-analysis. PloS one, 15(2), e0229268. https://doi.org/10.1371/journal.pone.0229268

Bermond, B., Oosterveld, P., & Vorst, H. C. (2015). Measures of alexithymia. In Measures of personality and social psychological constructs (pp. 227-256). Academic Press. https://doi.org/10.1016/B978-0-12-386915-9.00009-7

Boiardo, A. & Steele, M. (2021, May 26-27). Men in the Mirror: The Use of the Mirror Paradigm with Gay Men. [Conference presentation]. Association for Psychological Science. (Virtual).

Bond, M., Perry, J. C., Gautier, M., Goldenberg, M., Oppenheimer, J., & Simand, J. (1989). Validating the self-report of defense styles. Journal of Personality Disorders, 3(2), 101–112. https://doi.org/10.1521/pedi.1989.3.2.101

Buhl-Nielsen, B. (2006). Mirrors, body image and self. In International Congress Series (Vol. 1286, pp. 87-94). Elsevier. https://doi.org/10.1016/j.ics.2005.09.149

Buhl-Nielsen, B. (2017). Has the baby been given back? Insights from the mirror interview (plenary lecture). Contemporary Psychology and Practice, 11. http://www.psihologijanis.rs/dpp/arhiva/zbornik-12.pdf#page=11

Buhl-Nielsen, B. in collaboration with The Copenhagen Body Group, The BODI Group, and The New School Body Group (2008). The Mirror Interview and coding manual. Unpublished manuscript. University of Copenhagen and Department of Child and Adolescent Psychiatry, Region Sjaelland, Denmark.

Buhl-Nielsen, B., & Kernberg, P. (2015). Reflections in the Mirror-Body Image and Self. Recuperado el Julio de. https://www.ipa.world/images/ResearchPapers/146460buhlnielsonref.pdf

Cash, T. F. (2004). Body image: Past, present, and future [Editorial]. Body Image, 1(1), 1–5. https://doi.org/10.1016/S1740-1445(03)00011-1

Cash, T. F., & Pruzinsky, T. (Eds.). (1990). Body images: Development, deviance, and change. Guilford Press.

Cash, T. F., Theriault, J., & Annis, N. M. (2004). Body image in an interpersonal context: Adult attachment, fear of intimacy and social anxiety. Journal of social and clinical psychology, 23(1), 89-103. https://doi.org/10.1521/jscp.

Cattarin, J. A., & Thompson, J. K. (1994). A three-year longitudinal study of body image, eating disturbance, and general psychological functioning in adolescent females. Eating Disorders, 2(2), 114-125. https://doi.org/10.1080/10640269408249107

Cheng, H.-L., & Mallinckrodt, B. (2009). Parental bonds, anxious attachment, media internalization, and body image dissatisfaction: Exploring a mediation model. Journal of Counseling Psychology, 56(3), 365–375. https://doi.org/10.1037/a0015067

Collins, M. E. (1991). Body figure perceptions and preferences among preadolescent children. International Journal of eating disorders, 10(2), 199-208. https://doi.org/10.1002/1098-108X(199103)10:2%3C199::AID-EAT2260100209%3E3.0.CO;2-D

Cook-Cottone, C. (2016). Embodied self-regulation and mindful self-care in the prevention of eating disorders. Eating Disorders: The Journal of Treatment & Prevention, 24(1), 98–105. https://doi.org/10.1080/10640266.2015.1118954

Davern, M. T., Cummins, R. A., & Stokes, M. A. (2007). Subjective wellbeing as an affective-cognitive construct. Journal of Happiness Studies: An Interdisciplinary Forum on Subjective Well-Being, 8(4), 429–449. https://doi.org/10.1007/s10902-007-9066-1

DeNeve, K. M., & Cooper, H. (1998). The happy personality: A meta-analysis of 137 personality traits and subjective well-being. Psychological Bulletin, 124(2), 197–229. https://doi.org/10.1037/0033-2909.124.2.197

Di Pellegrino, G., Fadiga, L., Fogassi, L., Gallese, V., & Rizzolatti, G. (1992). Understanding motor events: a neurophysiological study. Experimental brain research, 91(1), 176-180. https://doi.org/10.1007/BF00230027

Eisler, R. M., Hersen, M., & Agras, W. S. (1973). Videotape: A method for the controlled observation of nonverbal interpersonal behavior. Behavior Therapy, 4(3), 420-425. https://doi.org/10.1016/S0005-7894(73)80123-6

Ensink, K., Berthelot, N., Biberdzic, M., & Normandin, L. (2016). The mirror paradigm: Assessing the embodied self in the context of abuse. Psychoanalytic Psychology, 33(3), 389–405. https://doi.org/10.1037/pap0000018

Erdem, C. (2019). The utilization of the Mirror Interview to explore attachment patterns, shame and body representations in adult men (2020-28120-151; Numeri 4-A) [ProQuest Information & Learning]. APA PsycInfo. http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip&db=psyh&AN=2020-28120-151&site=ehost-live

Ferrari, R. (2015). Writing narrative style literature reviews. Medical Writing, 24(4), 230-235. https://doi.org/10.1179/2047480615Z.000000000329

Fisher, S. (1964). Body image and psychopathology. Archives of General Psychiatry, 10(5), 519-529. https://doi.org/10.1001/archpsyc.1964.01720230081009

Fonagy, P., & Target, M. (2002). Early intervention and the development of self-regulation. Psychoanalytic Inquiry, 22(3), 307-335. https://doi.org/10.1080/07351692209348990

Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2002). Affect regulation, mentalization, and the development of the self. Other Press.

Fredrickson, B. L., & Roberts, T.-A. (1997). Objectification theory: Toward understanding women's lived experiences and mental health risks. Psychology of Women Quarterly, 21(2), 173–206. https://doi.org/10.1111/j.1471-6402.1997.tb00108.x

Friedrich, W. N., Fisher, J. L., Dittner, C. A., Acton, R., Berliner, L., Butler, J., Damon, L., Davies, W. H., Gray, A., & Wright, J. (2001). Child Sexual Behavior Inventory: normative, psychiatric, and sexual abuse comparisons. Child maltreatment, 6(1), 37–49. https://doi.org/10.1177/1077559501006001004

Fuchs, T., & Schlimme, J. E. (2009). Embodiment and psychopathology: a phenomenological perspective. Current opinion in psychiatry, 22(6), 570-575. https://doi.org/10.1097/YCO.0b013e3283318e5c

Gallese, V., & Ammaniti, M. (2014). La nascita dell’intersoggettività. Lo sviluppo del sé tra psicodinamica e neurobiologia. Cortina, Milano.

Gallese, V., Fadiga, L., Fogassi, L., & Rizzolatti, G. (1996). Action recognition in the premotor cortex. Brain, 119(2), 593-609. https://doi.org/10.1093/brain/119.2.593

Ganem, P. A., de Heer, H., & Morera, O. F. (2009). Does body dissatisfaction predict mental health outcomes in a sample of predominantly Hispanic college students? Personality and Individual Differences, 46(4), 557–561. https://doi.org/10.1016/j.paid.2008.12.014

Garner, D. M. (2004). Eating Disorder Inventory-3. Professional Manual. Lutz, FL: Psychological Assessment Resources, Inc

Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The eating attitudes test: psychometric features and clinical correlates. Psychological medicine, 12(4), 871–878. https://doi.org/10.1017/s0033291700049163

George, C., Kaplan, N., & Main, M. (1985). Adult Attachment Interview. Unpublished manuscript, University of California, Berkeley

Gilbert, P., Allan, S., & Goss, K. (1996). Parental representations, shame, interpersonal problems, and vulnerability to psychopathology. Clinical Psychology & Psychotherapy: An International Journal of Theory and Practice, 3(1), 23-34. https://doi.org/10.1002/(SICI)1099-0879(199603)3:1<23::AID-CPP66>3.0.CO;2-O

Green, B. N., Johnson, C. D., & Adams, A. (2006). Writing narrative literature reviews for peer-reviewed journals: secrets of the trade. Journal of chiropractic medicine, 5(3), 101-117. https://dx.doi.org/10.1016/S0899-3467(07)60142-6

Gross, J. J., & John, O. P. (2003). Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. Journal of Personality and Social Psychology, 85(2), 348–362. https://doi.org/10.1037/0022-3514.85.2.348

Gwyer, P. (2015). Clinical Interviewing. Unpublished work. https://doi.org/10.13140/rg.2.1.4411.9765.

Harter, S. (2016). I-self and me-self processes affecting developmental psychopathology and mental health. In D. Cicchetti (Ed.), Developmental psychopathology: Theory and method (p. 470–526). John Wiley & Sons, Inc.. https://doi.org/10.1002/9781119125556.devpsy111

Houben, M., Van Den Noortgate, W., & Kuppens, P. (2015). The relation between short-term emotion dynamics and psychological well-being: A meta-analysis. Psychological bulletin, 141(4), 901–930. https://doi.org/10.1037/a0038822

Jones, J. D., Cassidy, J., & Shaver, P. R. (2015). Parents’ self-reported attachment styles: A review of links with parenting behaviors, emotions, and cognitions. Personality and Social Psychology Review, 19(1), 44–76. https://doi.org/10.1177/1088868314541858

Juffer, F., & Steele, M. (2014). What words cannot say: the telling story of video in attachment-based interventions. Attachment & Human Development, 16(4), 307–314. https://doi.org/10.1080/14616734.2014.912484

Karatzias, A., Chouliara, Z., Power, K., & Swanson, V. (2006). Predicting general well-being from self-esteem and affectivity: an exploratory study with Scottish adolescents. Quality of life research: an international journal of quality of life aspects of treatment, care and rehabilitation, 15(7), 1143–1151. https://doi.org/10.1007/s11136-006-0064-2

Katznelson, H. (2014). Reflective functioning: A review. Clinical psychology review, 34(2), 107-117. https://doi.org/10.1016/j.cpr.2013.12.003

Kernberg, P. F. (1987). Mother-child interaction and mirror behavior. Infant Mental Health Journal, 8(4), 329–339. https://doi.org/10.1002/1097-0355(198724)8:4<329::AID-IMHJ2280080402>3.0.CO;2-F

Kernberg, P. F., & Normandin, L. (1999). Toddler mirror paradigm: Coding system of behaviour in front of the mirror for clinical and research purposes. Unpublished document.

Kernberg, P. F., & Normandin, L. (2002). Mirror interview for children. Unpublished document.

Kernberg, P. F., Buhl-Nielsen, B., & Normandin, L. (2007). Beyond the reflection: The role of the mirror paradigm in clinical practice. Other Press.

Kling, J., Kwakkenbos, L., Diedrichs, P. C., Rumsey, N., Frisen, A., Brandao, M. P., Silva A.G., Dooley, B., Rodgers, R.F., & Fitzgerald, A. (2019). Systematic review of body image measures. Body Image, 30, 170-211. https://doi.org/10.1016/j.bodyim.2019.06.006

Knafo, H. (2016). The Intergenerational Transmission of Body Image: A Study of the Mirror Interviews of Five-to Seven-Year-Old Girls and Their Mothers (Doctoral dissertation, The New School).

Krueger, D. W. (2001). Body self: Development, psychopathologies, and psychoanalytic significance. The Psychoanalytic Study of the Child, 56, 238–259.

Krueger, D. W. (2013). Integrating body self & psychological self. Routledge.

Lacan, J. (1949). The mirror stage as formative of the function of the I as revealed in psychoanalytic experience. Reading French Psychoanalysis, 119-26.

Laporta-Herrero, I., Jáuregui-Lobera, I., Serrano-Troncoso, E., Garcia-Argibay, M., Cortijo-Alcarria, M. C., & Santed-Germán, M. A. (2020). Attachment, body appreciation, and body image quality of life in adolescents with eating disorders. Eating disorders, 1-14. https://doi.org/10.1080/10640266.2020.1763112

Marco, J. H., Cañabate, M., Pérez, S., & Llorca, G. (2017). Associations among meaning in life, body image, psychopathology, and suicide ideation in Spanish participants with eating disorders. Journal of clinical psychology, 73(12), 1768-1781. https://doi.org/10.1002/jclp.22481

Marzola, E., Cuzzolaro, M., & Abbate-Daga, G. (2018). Body Image: Methods of Assessment in Children, Adolescents, and Adults. In M. Cuzzolaro & S. Fassino (A c. Di), Body Image, Eating, and Weight: A Guide to Assessment, Treatment, and Prevention (pagg. 39–55). Springer International Publishing. https://doi.org/10.1007/978-3-319-90817-5_3

McBirney-Goc, E. (2016). The mirror interview: Exploring the influences of parents and culture on the body and disordered eating behaviors (2015-99100-128; Numeri 11-B(E)) [ProQuest Information & Learning]. APA PsycInfo. http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip&db=psyh&AN=2015-99100-128&site=ehost-live

McKinley, N. M., & Hyde, J. S. (1996). The objectified body consciousness scale: Development and validation. Psychology of Women Quarterly, 20(2), 181–215. https://doi.org/10.1111/j.1471-6402.1996.tb00467.x

Muzi, S. (2020). A narrative review on alexithymia in adolescents with previous adverse experiences placed for adoption, in foster care, or institutions. Prevalence, gender differences, and relations with internalizing and externalizing symptoms. Mediterranean Journal of Clinical Psychology, 8(2). https://doi.org/10.6092/2282-1619/mjcp-2449

Muzi, S., & Pace, C. S. (2021). Multiple facets of attachment in residential-care, late adopted, and community adolescents: an interview-based comparative study. Attachment & Human Development, 1-20. https://doi.org/10.1080/14616734.2021.1899386

Pace, C. S., Di Folco, S., Guerriero, V., & Muzi, S. (2019). Late-adopted children grown up: a long-term longitudinal study on attachment patterns of adolescent adoptees and their adoptive mothers. Attachment & Human development, 21(4), 372–388. https://doi.org/10.1080/14616734.2019.1571519.

Pace, C.S., Guiducci, V., & Cavanna, D. (2017). Attachment in eating-disordered outpatients with and without borderline personality disorder. Journal of Health Psychology, 22(14), 1808-1818. https://doi.org/10.1177/135910531663695

Pace, C. S., Muzi, S., & Steele, H. (2020). Adolescents’ attachment: Content and discriminant validity of the friends and family interview. Journal of Child and Family Studies, 29(4), 1173-1186. https://doi.org/10.1007/s10826-019-01654-8

Priebe, S., & Röhricht, F. (2001). Specific body image pathology in acute schizophrenia. Psychiatry Research, 101(3), 289–301. https://doi.org/10.1016/S0165-1781(01)00214-1

Probst, M., Pieters, G., Vancampfort, D., & Vanderlinden, J. (2008). Body experience and mirror behaviour in female eating disorders patients and non clinical subjects. Psihologijske teme, 17(2), 335-348. https://hrcak.srce.hr/index.php?show=clanak&id_clanak_jezik=51644

Putnam, F. W., Helmers, K., & Trickett, P. K. (1993). Development, reliability, and validity of a child dissociation scale. Child Abuse & Neglect, 17(6), 731-741. https://doi.org/10.1016/S0145-2134(08)80004-X

Ricciardelli, L. A., & McCabe, M. P. (2001). Children's body image concerns and eating disturbance: A review of the literature. Clinical psychology review, 21(3), 325-344. https://doi.org/10.1016/S0272-7358(99)00051-3

Rizzolatti, G., Fadiga, L., Gallese, V., & Fogassi, L. (1996). Premotor cortex and the recognition of motor actions. Brain research. Cognitive brain research, 3(2), 131–141. https://doi.org/10.1016/0926-6410(95)00038-0

Rosenfeld, H. (1964). On the psychopathology of narcissism: A clinical approach. The International Journal of Psychoanalysis, 45(2-3), 332–337.

Ruffolo, J. S., Phillips, K. A., Menard, W., Fay, C., & Weisberg, R. B. (2006). Comorbidity of Body Dysmorphic Disorder and Eating Disorders: Severity of Psychopathology and Body Image Disturbance. International Journal of Eating Disorders, 39(1), 11–19. https://doi.org/10.1002/eat.20219

Samuel, S., & Akhtar, S. (2009). The Identity Consolidation Inventory (ICI): Development and application of a questionnaire for assessing the structuralization of individual identity. The American Journal of Psychoanalysis, 69(1), 53–61. https://doi.org/10.1057/ajp.2008.39

Schneider, N., Martus, P., Ehrlich, S., Pfeiffer, E., Lehmkuhl, U., & Salbach-Andrae, H. (2009). The assessment of body image distortion in female adolescents with anorexia nervosa: The development of a test for body image distortion in children and adolescents (BID-CA). Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 14(2-3), e128-e136. https://doi.org/10.1007/bf03327810

Schultheis, A. M., Mayes, L. C., & Rutherford, H. J. (2019). Associations Between Emotion Regulation and Parental Reflective Functioning. Journal of child and family studies, 28(4), 1094–1104. https://doi.org/10.1007/s10826-018-01326-z

Steele, H., & Siever, L. (2010). An attachment perspective on Borderline Personality Disorder: Advances in gene-environment considerations. Current Psychiatry Reports, 12, 61-67. https://doi.org/10.1007/s11920-009-0091-0

Steele, H., & Steele, M. (2005). The construct of coherence as an indicator of attachment security in middle childhood: The Friends and Family Interview. In K. Kerns & R. Richardson (Eds.), Attachment in middle childhood (pp. 137–160). Guilford Press.

Steele, M., Bate, J., Nikitiades, A., & Buhl-Nielsen, B. (2015a). Attachment in adolescence and borderline personality disorder. Journal of infant, child, and adolescent psychotherapy, 14(1), 16-32. https://doi.org/10.1080/15289168.2015.1004882

Steele, M., Murphy, A., & Steele, H. (2015b). The Art and Science of Observation: Reflective Functioning and Therapeutic Action. Journal of Infant, Child, and Adolescent Psychotherapy, 14(3), 216–231. https://doi.org/10.1080/15289168.2015.1070558

Steele, M., Steele, H., Bate, J., Knafo, H., Kinsey, M., Bonuck, K., Meisner, P., & Murphy, A. (2014). Looking from the outside in: The use of video in attachment-based interventions. Attachment & Human Development, 16(4), 402–415. https://doi.org/10.1080/14616734.2014.912491

Suardi, F., Moser, D. A., Sancho Rossignol, A., Manini, A., Vital, M., Merminod, G., Kreis, A., Ansermet, F., Rusconi Serpa, S., & Schechter, D. S. (2018). Maternal reflective functioning, interpersonal violence-related posttraumatic stress disorder, and risk for psychopathology in early childhood. Attachment & Human Development. Advance online publication. https://doi.org/10.1080/14616734.2018.1555602.

Tangney, J. P., Dearing, R. L., Wagner, P. E., & Gramzow, R. (2000). Test of Self-Conscious Affect–3 (TOSCA-3) [Database record]. APA PsycTests. https://doi.org/10.1037/t06464-000

Tiggemann, M., & Wilson-Barrett, E. (1998). Children's figure ratings: Relationship to self-esteem and negative stereotyping. International Journal of Eating Disorders, 23(1), 83–88. https://doi.org/10.1002/(SICI)1098-108X(199801)23:1<83::AID-EAT10>3.0.CO;2-O

Tommasi, M., Grassi, P., Balsamo, M., Picconi, L., Furnham, A., & Saggino, A. (2018). Correlations between personality, affective and filial self-efficacy beliefs, and psychological well-being in a sample of Italian adolescents. Psychological reports, 121(1), 59-78. https://doi.org/10.1177/0033294117720698

Tremblay, L., & Limbos, M. (2009). Body image disturbance and psychopathology in children: research evidence and implications for prevention and treatment. Current Psychiatry Reviews, 5(1), 62-72. https://doi.org/10.2174/157340009787315307

Truby, H., & Paxton, S. J. (2008). The Children's Body Image Scale: Reliability and use with international standards for body mass index. British Journal of Clinical Psychology, 47(1), 119-124. https://doi.org/10.1348/014466507x251261

Tylka, T. L., & Wood-Barcalow, N. L. (2015). The Body Appreciation Scale-2: Item refinement and psychometric evaluation. Body Image, 12, 53–67. https://doi.org/10.1016/j.bodyim.2014.09.006

Van Tergouw, M. (2011). Peer Influences on the Body Satisfaction of Adolescent Girls: Where Do We Go from Here?. Social cosmos, 2, 104-110.

Veale, D., & Riley, S. (2001). Mirror, mirror on the wall, who is the ugliest of them all? The psychopathology of mirror gazing in body dysmorphic disorder. Behaviour research and therapy, 39(12), 1381-1393. https://doi.org/10.1016/S0005-7967(00)00102-9

Werner, A. M., Tibubos, A. N., Rohrmann, S., & Reiss, N. (2019). The clinical trait self-criticism and its relation to psychopathology: A systematic review—Update. Journal of Affective Disorders, 246, 530–547. https://doi.org/10.1016/j.jad.2018.12.069

Winnicott, D. W. (1967). Mirror-role of mother and family in child development. New York, NY: Routledge

Yilmaz, T., & Bozo, Ö. (2019). Whose gaze is more objectifying? An experimental study of college women’s state self-objectification, body shame, negative mood, and body dissatisfaction. Mediterranean Journal of Clinical Psychology, 7(2). https://doi.org/10.6092/2282-1619/2019.7.2108

DOI: https://doi.org/10.13129/2282-1619/mjcp-3025


  • There are currently no refbacks.