Group counseling intervention module cognitive behavioral therapy effectiveness in addressing the problems of body dissatisfaction, anxiety and self-esteem in higher education institution teenagers

This pilot study examines body image dissatisfaction, anxiety, and self-esteem, particularly among university and college students, which can significantly impact their mental well-being. Obsession with weight satisfaction and physical attractiveness can lead to depression, eating disorders, and social disorders. Twenty Psychology and Education students participated in this study, using tools such as the multidimensional body self-relations questionnaire-appearance scale, the physical appearance state and trait anxiety scale, and the body esteem scale for adolescents and adults. Additionally, a Cognitive Behavioral Group Counseling Intervention Module was utilized to restructure thinking and modify behavior. The module results of 0.897 suggested that this intervention can help individuals change their assumptions and beliefs regarding self-image dissatisfaction, particularly on physical appearance.


INTRODUCTION
Adolescent development and well-being are heavily influenced by body image, as noted by Markey (2010).Newman and Newman (2016) distinguish between two stages of adolescence: early adolescence, spanning ages 12 to 18, and late adolescence, from 18 to 24.This period is characterised by numerous hardships and societal pressures.Adolescents go through substantial physical changes, such as growth spurts and puberty, which affect their look and stature.As a result, adolescents may develop increased dissatisfaction with their bodies, jeopardizing their well-being.Markey (2010) highlights the correlation between poor body image and various mental health issues, including depression, anxiety, eating disorders, and low self-esteem.
The human body stands as the most conspicuous physical attribute, coveted by many for its beauty.
Achieving an attractive appearance is a universal aspiration, as it holds the potential for favorable social interactions and even financial gain, as noted by Pop (2016).Pop emphasizes the pivotal role of physical appearance in initial social encounters and suggests that it dictates an individual's societal acceptance.Thus, it should come as no surprise that today's youth spend large sums of money-often thousands of ringgitsin order to improve their physical appearance in order to get acceptance in society.The prevalence of anxiety and dissatisfaction with body image among teenagers, particularly in Higher Education Institutes, is a significant concern, as highlighted by Liao et al. (2010).This issue often escalates into depression and stress, exacerbating its detrimental effects, as noted by Baptista et al. (2012).Notably, the repercussions extend beyond mental health, affecting interpersonal relationships and academic performance.Hart et al. (2008) categorize body image dissatisfaction as a manifestation of social appearance concerns or physical social concerns, emphasizing individuals' preoccupation with how others perceive them.This preoccupation manifests as social anxiety, leading individuals to shy away from unfamiliar social interactions and engage in frequent self-comparisons (American Psychiatric Association, 2013).
In the context of Higher Education Institutes, this anxiety is closely linked to diminished self-esteem and a compromised quality of life among students (Izgiç et al., 2004).In order to lessen the detrimental effects of body image issues on psychological health and academic achievement, therapies addressing these issues are desperately needed.Kowaliski et al. (2007) highlight the intricate relationship between appearance anxiety and self-esteem, indicating that individuals with low self-esteem perceive themselves as less liked and valued by others, perpetuating a cycle of diminished self-worth.This problem is worsened by cultural prejudices that prefer people with cleaner outward looks, flattering body proportions, and adherence to current fashion trends.Individuals whose appearance deviates from cultural norms, such as those with larger bodies, darker skin tones, or unorthodox fashion choices, are frequently discriminated against and marginalized in their social groups.
Research by Abdollahi et al. (2016) corroborates this, illustrating how teenagers with negative body images, such as being perceived as overweight, having dark skin, or being shorter, become targets of peer bullying.The emphasis on physical appearance in peer criticism can have a significant impact on victims, making it difficult for them to navigate daily life and undermining their confidence.This highlights the critical need for initiatives that promote body acceptance and counteract societal stereotypes, creating situations in which people of all shapes and sizes feel respected and accepted.The study of Christiana et al. (2015, also confirmed that poor body image is associated with a worse quality of life in all of its dimensions: physical, environmental, social relationships and especially the psychological dimension.In accordance with Cash (2012), the complex issue of body image dissatisfaction, anxiety, and selfesteem encompasses cognitive, perceptual, and behavioral dimensions.Cognitive aspects include people's thoughts and opinions about themselves, whereas perception pertains to how others judge their bodies.The behavioral component refers to people's activities and treatment of their bodies.The researcher's goal in this study is to address these characteristics by reorganizing cognitive patterns and changing habits that interfere with people's daily functioning.Participants will be directed through the implementation of a behavioral cognitive intervention module to test and update their ideas and beliefs about self-image dissatisfaction, particularly in terms of physical appearance.By focusing on these cognitive and behavioral processes, the intervention hopes to promote positive changes in people's opinions of themselves and their bodies, resulting in increased well-being and self-esteem.

METHODS
In this pilot study conducted at a public university in Malaysia, participants comprised both male and female students.Employing an experimental method within the quantitative research paradigm, the study focused on addressing body image dissatisfaction, anxiety, and self-esteem issues.A total of 20 students, evenly distributed, with 10 females and 10 males, were randomly selected for participation.The sampling process involved random selection, ensuring unbiased representation among participants (Creswell et al., 2017).Prior to the counselling sessions, participant data underwent screening to identify individuals with high scores in body image dissatisfaction, anxiety, and low self-esteem, who were then assigned to the treatment group.Conversely, individuals with moderate to satisfactory scores were transferred to the control group (Jacobs et al., 2012).
Two treatment groups, segregated by gender, underwent six counselling sessions utilizing the Counseling Behavioral Cognitive Intervention Module.Meanwhile, the control group also received counselling using the same intervention module following the conclusion of treatment sessions for the treatment group.This approach facilitated a systematic evaluation of the intervention's effectiveness in addressing body image dissatisfaction, anxiety, and self-esteem among university students, offering valuable insights into potential interventions tailored to this demographic.

Demographics
This questionnaire is divided into two parts.Part A is related to demographic information that covers the background, which contains nine items that have been constructed to make analysis and comparison.

Multidimensional Body Self-Relation Questionnaire (Appearance Scale)
MBSRQ-AS questionnaire has a 34-item version of the instrument, consisting only of the five appearance-related subscales (Appearance Evaluation, Appearance Orientation, Overweight Preoccupation, Self-Classified Weight, and the Body Areas Satisfaction Scale).The answer scale is assessed using five Likert scales, namely, 1: Strongly Disagree, 2: Disagree, 3: Not Sure, 4: Agree and 5: Strongly Agree.Cash (2000) recommended using this version when researchers are only or primarily interested in appearance-focused body image.Cash (2000) also reported adequate internal consistency coefficients across all MBSRQ subscale scores (Cronbach's women ≥ .74,men ≥ .70)and adequate 1-month test-retest reliabilities.An exploratory factor analysis revealed that the MBSRQ-AS items significantly loaded with the scale's main factors.Internal consistencies of the subscales ranged from .76 to .86.Test-retest reliabilities ranged from .75 to .93.
Convergent validity was also confirmed as the MBSRQ-AS subscales correlated positively (Marios et al., 2013).

Physical Appearance State and Trait Anxiety Scale (PASTAS)
The Physical Appearance State and Trait Anxiety Scale (PASTAS; Reed et al., 1991) measures anxiety related to specific body parts as well as anxiety about the overall body image.This instrument contains 16 items that assess state and trait dimensions of anxiety.The answer scale is evaluated from 0 to 4, which is 0: Not at all, 1: A little, 2: Moderately, 3: Agree and 4: Very unusual.For the trait anxiety item, people are asked about how they feel about their body in general and their answers are scored from 0 (not at all) to 4 (very important).Test-retest reliability is .87,and Cronbach's alpha is from .82 to .92 (Reed et al., 1991).

The Body-Esteem Scale for Adolescents and Adults (BESAA)
The Body-Esteem Scale for Adolescents and Adults was designed by Mendelson et al., (2001).This

Activities in Cognitive Behavioral Group Counselling Module
In order to implement the intervention as a researcher, it is necessary to build a module that has high validity.Abu Bakar Nordin (1995) stated that a level of mastery or achievement of 70% is considered to have mastered or reached a high level.Therefore, before conducting the pilot study, the researcher asked three module panel experts in the field of psychology to review this intervention module, and the score received by the researcher was 80%, so this Body Image behavioral, cognitive intervention module can be used as a module.This intervention module has six meeting sessions conducted for both groups.The meeting has been divided into three stages, namely the beginning stage, the middle or working stage and the termination or closing stage (Jacob et al., 2009).After the end of the counselling session for this pilot study, the researcher asked the respondents to fill out a module reliability questionnaire.The Cronbach Alpha's score for the intervention module is 0.879 for 75 items, which is considered an appropriate score for reliability.
According to Griethuijsen et al., (2014), the acceptable significant value for Cronbach's Alpha is 0.7 and above, and this shows that this cognitive behavior group counselling intervention module can be used.

Data Analysis
In order to analyze the data findings of the pilot study, SPSS version 26 is being used.A nonparametric Wilcoxon Signed Rank test was done to compare the mean difference between pre-intervention and post-intervention.

Result
A non-parametric test, specifically the Wilcoxon signed rank test, is used to compare the pre-intervention and post-intervention variables.Below are the tables to present the data findings.The Wilcoxon signed rank test reveals that the post-intervention scores for the Multidimensional Body-Self Relation Questionnaire are lower (Mdn=2.68,N=20) compared to pre-intervention scores (Mdn=3.69,N=20), z= -3.92, p= 0.001 with a large effect size r= 0.87.This means that there is a significant difference between pre-intervention and post-intervention for the MBSRQ score among the participants of the study.The Wilcoxon signed rank test reveals that the post-intervention scores for the Physical Anxiety and Trait Anxiety Questionnaire are lower (Mdn=0.56,N=20) compared to pre-intervention scores (Mdn=1.90,N=20), z= -3.92, p= 0.001 with a large effect size r= 0.87.This means that there is a significant difference between pre-intervention and post-intervention for PASTAS scores among the participants of the study.The Wilcoxon signed rank test reveals that the post-intervention scores for the Body Esteem Scale for Adolescents and Adults are higher (Mdn=3.08,N=20) compared to pre-intervention scores (Mdn=2.54,N=20), z= -3.42, p= 0.001 with a large effect size r= 0.76.This means that there is a significant difference between pre-intervention and post-intervention for BESAA scores among the participants of the study.
This concludes the non-parametric Wilcoxon signed rank test for all three questionnaires collected for the pilot study.pivotal approach utilized in treatment and rehabilitation programs tailored to address body image concerns (Cash, 2019).Individuals experiencing recurrent negative self-perceptions often find themselves ensnared in feelings of anxiety, which subsequently erode their self-esteem and impede their ability to engage socially.
As Adinda et al. ( 2012) elucidate, low self-esteem can precipitate a cascade of adverse outcomes, including diminished motivation, social withdrawal due to shyness, and compromised academic performance.
Furthermore, individuals grappling with low self-esteem are predisposed to experiencing heightened levels of depression and anxiety (Aditomo, 2004) intervention for addressing body image dissatisfaction.In Cash's study, which encompassed male and female university students selected at random, a significant 93% of participants reported positive effects, including reduced investment in body image concerns and an overall improvement in emotional well-being.Moreover, an overwhelming 98% expressed satisfaction with the treatment services provided.Body image serves as a fundamental aspect of self-representation, profoundly influencing how individuals perceive themselves and are perceived by others.Particularly among teenagers, the pursuit of an idealized body shape is often fueled by societal expectations and norms.However, it is crucial to challenge the perception of "perfection" associated with body image, as the relentless pursuit of unattainable standards can perpetuate negative feelings of dissatisfaction and stress.Such persistent negative emotions surrounding body image can significantly impact an individual's mental health and daily functioning.
The results pertaining to anxiety issues within the treatment group, following the implementation of the cognitive behavioral intervention module, yielded positive outcomes.The mean reduction in anxiety levels observed after participating in six counseling sessions using the module was 13%.Supporting these findings, a combined study by Strachan & Cash (2002)   behavior changed in favorable ways, such as reduced impulses to evaluate or compare themselves to others, less investment in appearance, and reduced susceptibility to external influences.Furthermore, participants reported higher self-esteem, lower spending on appearance-related products, greater body pleasure, lower anxiety about weight gain, and less uncertainty in a variety of situational scenarios.These findings highlight the effectiveness of cognitive behavioral therapies in fostering positive self-perception and reducing the negative impacts of body image dissatisfaction on people's self-esteem and overall well-being.
In summary, the results of this pilot study show that all four key assumptions were confirmed.Despite the small sample size, the findings show that the cognitive behavioral group counseling intervention module is effective in addressing body image dissatisfaction, anxiety, and low self-esteem among participants.These findings are consistent with previous research by Stice et al. (2021), which underscores the effectiveness of the cognitive behavioral approach in tackling these concerns among university students aged 18 to 21.The prevalence of negative body image concerns among university students, as evidenced by prior studies, highlights the significance of addressing these issues within the context of Higher Education Institutes.
Excessive preoccupation with external evaluations can detrimentally impact both physical and academic wellbeing.Additionally, research by Marco et al., (2013) suggests that advancing age, particularly among individuals aged 18 to 27, may exacerbate concerns about body image, potentially influencing lifestyle choices and contributing to unhealthy behaviors such as sedentary lifestyles and poor dietary habits (Cecchini et al., 2010).
Overall, these findings highlight the necessity of establishing interventions to address body image concerns among university students, particularly those attending Higher Education Institutes.We can reduce the negative effects of body image dissatisfaction, anxiety, and self-esteem concerns by delivering effective cognitive behavioral therapies, boosting students' overall well-being and academic achievement.

Suggestions
Based on the conducted research, several recommendations emerge for enhancing future studies in this field.Firstly, researchers should deepen their examination of factors contributing to body image dissatisfaction, anxiety, and self-esteem.This entails considering demographic variables such as parents' income, rural or urban residence, and ethnic background.By comprehensively analyzing these demographic factors, researchers may uncover nuanced differences that directly or indirectly influence body image dissatisfaction, anxiety, and self-esteem.This broader approach to demographic analysis can shed light on the complex interplay between socioeconomic status, cultural influences, and individual perceptions of body image.Moreover, it can help identify specific demographic groups that may be particularly vulnerable to body image concerns, thus informing targeted interventions and support strategies.

CONCLUSION
In summary, this pilot study highlights the prevalence of image dissatisfaction, anxiety, and low selfesteem issues among Malaysian university students.The observed correlation between body image dissatisfaction and comparison tendencies underlines the potential impact on individuals' psychological wellbeing, contributing to disorders such as depression, anxiety, and compromised self-esteem (Grogan, 2016).
questionnaire contains 23 items and three subscales, namely appearance, attribution and body weight.The rated Likert scale type is 0: No, 1: Rarely, 2: Sometimes, 3: Often and 4: Always; higher scores indicate more positive body values.Mendelson et al. (2001) reported acceptable internal consistency for the three selfesteem subscales, with Cronbach's alpha ranging from .75 to .96.Cognitive Behavioral Group Counseling ModuleActivity (Stage 1: Explanation) Session 1 : Building Therapeutic Relationship and Cohesiveness Among Group Members Activity 1: Introduction and Counseling Structuring Activity 2: Building Relationship and Group Members Introduction "Ice Breaking" Activity 3: Final Formulation and Session Closing (Stage 2: Problem Identification) Session 2: Understanding Body Image Dissatisfaction, Anxiety, and Self-Esteem Activity 1: What is Body Image Dissatisfaction, Anxiety, and Self-Esteem?Activity 1: Initial Formulation and Follow-up Activity 2: Drawing "Myself" Portrait Activity 3: Identifying Negative Events Activity 4: Relaxation Exercise Activity 5: Final Formulation and Session Closing Initial Formulation and Follow-up Activity 2: Self-Change Activity 3: Final Formulation and Session Closing

MODULE
's score for the Intervention Module is 0.897 for 79 items, which is considered an appropriate score for reliability.This shows that the Cognitive Behavioral Group Counseling Intervention Module can be used.Discussion The Cognitive Behavioral Module serves as the cornerstone of support in this pilot study, aimed at assisting individuals grappling with body image dissatisfaction, anxiety, and self-esteem issues by fostering positive cognitive restructuring and behavioral modification.Cognitive behavioral therapy (CBT) emerges as a . Thus, the Cognitive Behavioral Module employed in this pilot study endeavors to empower individuals to challenge and reframe their negative cognitions, thereby fostering a more positive self-image and enhancing their psychological well-being.Through targeted cognitive restructuring and behavioral interventions, the module aims to equip participants with coping mechanisms to navigate and alleviate the adverse impacts of body image dissatisfaction, anxiety, and low self-esteem.The research problem addressed by the cognitive behavioral group counselling intervention focuses on individuals, particularly students of Higher Education Institutes, who grapple with body image dissatisfaction, anxiety, and low self-esteem issues.These challenges stem from a multitude of factors, including self-esteem, identity, and various socio-cultural influences such as culture, race, socioeconomic status, belief values, needs, experiences, and societal perceptions.Rozimah & Bukhary (2017)  emphasize that these factors contribute to individuals' negative thoughts about their body image, prompting them to compare themselves unfavorably with others in terms of physical appearance, body shape, and other attributes.Consequently, individuals experience a pervasive sense of dissatisfaction with their bodies, which can significantly impact their psychological well-being and quality of life.Cognitive Behavioral Therapy (CBT) emerges as a prominent treatment modality aimed at addressing individuals' negative thoughts by restructuring their cognitive patterns.This approach equips individuals with strategies to adapt to triggers that may elicit aggressive behavior.CBT has garnered widespread popularity and is recognized as a cornerstone of therapeutic rehabilitation programs, particularly in addressing behavioral challenges among young individuals(Cash, 2019).Building upon the robust foundation of previous research and supported by expert panel evaluations of counselling and psychology modules, the researcher is convinced of the efficacy of the Cognitive Behavioral Intervention Module in addressing the issues of body image dissatisfaction, anxiety, and self-esteem.This module, grounded in the principles of CBT, offers a structured framework to assist respondents in challenging and reframing their negative thought patterns, thereby fostering positive cognitive restructuring and behavioral adaptation.The cognitive behavioral group counselling intervention module comprises six sessions designed to address negative body image using cognitive behavioral techniques.These sessions are tailored to treat symptoms through cognitive restructuring and behavior modification, fostering self-awareness and empowering individuals to navigate their conditions effectively.Participants engage in various cognitive behavioral techniques, including psychoeducation, cognitive restructuring, relaxation, self-talk, modeling, and monitoring.Additionally, individuals are assigned homework tasks after each session to monitor their cognitive and behavioral progress.Therapists can utilize the cognitive behavioral group counseling intervention module manual on body image to assist individuals grappling with image dissatisfaction, anxiety, and low self-esteem issues.Through this approach, participants are guided to identify underlying causes and cultivate self-acceptance.Counselling or psychotherapy approaches have been shown to bolster self-confidence and adaptive capacity by alleviating anxiety and enhancing self-esteem among students(Velayudhan et al., 2010).By integrating these techniques into the intervention module, therapists aim to empower individuals to navigate their body image concerns and foster a positive sense of self.The results of the pilot study demonstrate the effectiveness of the Cognitive Behavioral Intervention module in addressing the challenges faced by participants experiencing body image dissatisfaction, anxiety, and low self-esteem issues.The high Cronbach's Alpha coefficient of 0.897 indicates the reliability of the intervention module, affirming its utility in therapeutic applications.As highlighted by Gusman (2021), the cognitive behavioral therapy approach enhances individuals' awareness of their thoughts and behaviors, providing a framework for targeted intervention.Building upon this foundation, the researchers conducted six group counseling sessions with the treatment group, offering tailored support to address their specific concerns related to body image dissatisfaction, anxiety, and self-esteem.Furthermore, existing literature supports the efficacy of cognitive behavioral therapy as a viable alternative for individuals grappling with these issues(Stice et al., 2021).These findings underscore the promising role of cognitive behavioral interventions in promoting psychological well-being and enhancing coping mechanisms for individuals experiencing body image dissatisfaction, anxiety, and low self-esteem concerns.The results of the study regarding body image dissatisfaction among the treatment group revealed a notable positive change, with 99% of participants experiencing improvement after engaging in group counseling sessions utilizing the cognitive behavioral intervention module.These findings are consistent with the outcomes ofLewis et al.'s (2019)  study, which employed a similar cognitive behavioral therapy (CBT) environment for university students to thrive.By addressing these underlying societal influences and providing effective interventions like cognitive behavioral therapy, we can mitigate the adverse impact of unrealistic beauty standards on individuals' mental health and overall success.The study's final outcome addressed the issue of self-esteem in relation to body image dissatisfaction, and the use of the cognitive behavioral intervention module produced encouraging outcomes.Participants in the treatment group demonstrated significant improvements in self-esteem concerning body image, with the mean level of self-esteem increasing to 56% following six group counseling sessions using the module.These findings align with the results of a study by Molly & Monica (2015), which investigated the impact of Cognitive Behavioral Treatment on individuals' behavior and self-esteem.The study found that participants' Another recommendation for future research is to increase the study sample size by including a more diverse range of public and private universities in Malaysia.This expansion aims to enhance the generalizability of study findings to the broader student population across different types of institutions.By including a broader representation of universities, researchers can capture a more comprehensive understanding of the prevalence and impact of body image dissatisfaction, anxiety, and self-esteem among Malaysian students.By conducting research across various university settings, this study can serve as a platform to raise awareness among Malaysians about the pervasive nature of these issues among students in Malaysia.By shedding light on the prevalence of body image concerns across different educational contexts, this research can contribute to efforts aimed at addressing these issues on a national scale.Furthermore, it is recommended that researchers studying body image dissatisfaction consider additional factors such as the respondent's Body Mass Index (BMI), lifestyle practices, and nutritional diet.By incorporating these variables into the research design, researchers can gain a more comprehensive understanding of the complexities surrounding body image distortion and its relationship with other factors under investigation.Examining BMI, lifestyle choices, and dietary habits can provide valuable insights into how these factors contribute to body image concerns and their potential impact on psychological well-being.This holistic approach will enrich future studies and facilitate a more nuanced understanding of body image dissatisfaction among individuals.Finally, for researchers interested in studying the effectiveness of cognitive behavioral intervention modules, it is recommended to diversify techniques or employ a combination of Cognitive Behavioral Therapy (CBT) approaches.By incorporating various CBT techniques, researchers can enhance the effectiveness of the intervention module and provide individuals with a more comprehensive toolkit to address body image dissatisfaction, anxiety, and self-esteem issues.Moreover, the adoption of diverse CBT techniques can contribute to therapists in Malaysia by equipping them with versatile strategies to assist individuals in overcoming these challenges effectively.This approach not only enhances the impact of cognitive behavioral interventions but also fosters positive behavioral changes and promotes mental wellbeing among individuals grappling with body image concerns.

Table 2 .
Wilcoxon signed rank test on Multidimensional Body-Self Relation Questionnaire Pre-Intervention and Post-Intervention

Table 3 .
Descriptive statistic table for Physical Appearance and Trait Anxiety Questionnaire for Pre-

Table 5 .
Descriptive statistic table for Body Esteem Scale for Adolescents and Adults for Pre-Intervention and

Table 6 .
Wilcoxon signed rank test on Body Esteem Scale for Adolescents and Adults Pre-Intervention and demonstrated the efficacy of Cognitive Behavioral Therapy (CBT) intervention techniques, such as psychoeducation and self-monitoring, in addressing body image concerns.Conducted over six treatment sessions with separate groups for men and women, the study reported a significant reduction in anxiety levels among participants.For instance, anxiety levels decreased from 14% to 53% in the female treatment group and from 14% to 53% in the male treatment group.Furthermore, Humberto et al. (2014) highlighted that body image concerns among university students often stem from societal pressures to conform to prevailing cultural ideals of beauty and perfection.This preoccupation with achieving an "ideal" appearance can exert detrimental effects on mental health, academic performance, and interpersonal relationships, particularly among young women.Thus, challenging and redefining societal standards of beauty is crucial in promoting holistic well-being and fostering a supportive