The Internet: Friend or Foe for Treating Eating Disorders?

At the recent National Eating Disorders Association (NEDA) meeting in Bethesda, MD, Kathleen Burns Kingsbury, LMHC, and Sarah R. Brotsky, PsyD outlined the benefits and drawbacks of the Internet as an adjunct to traditional therapy for eating disorders patients (see also article on page 1).

An Inside View of Pro-ED Websites

Dr. Brotsky, a clinical psychologist, told the audience about her project to investigate online pro-Ana websites in depth. She went “undercover,” posing as a person with an eating disorder, to try to understand the inner workings of pro-Ana sites and why they are so appealing to patients with eating disorders.

Dr. Brotsky said, “Within the pro-eating disorders community, the Internet has provided these individuals with support. We need to be familiar with this and to talk about it with clients. Be open to hearing about them, be an advocate for clients, and let them know they are being heard. Don’t be afraid to look, because it isn’t going away,” she stressed.

After analyzing about 30 different chat room sites and after enrolling as a member in 24 online sites, Dr. Brotsky found a number of recurring themes.

Connections and group norms. “The process of becoming a member of pro-Ana sites is so easy that it is scary,” said Dr. Brotsky. Lots of individuals want to connect with the larger community online and feel they have a common goal, she said. New members were warmly welcomed to the sites with comments such as ‘Good luck, hugs and kisses.’ Participants regularly shared photos, animated drawings, and personal information. Members could post polls and the community would participate. When Dr. Brotsky posted a questionnaire (as a member), to see if pro-Ana or pro-limia was a lifestyle or a choice, of 232 members who responded, 131 reported they felt it was a disorder. There were often subcommunities on the website, too. Members of these subcommunities provided comments such as, ‘Welcome to a community where a person can live with an eating disorder, and a place to get support.’

Strong group identity and the possibility of rejection. Dr. Brotsky reported that one characteristic of the websites was a strong group identity. She also noted that she was rejected from a site where applicants had to submit an application and members voted upon the applicants. Dr. Brotsky was surprised at some of the responses; for example, some members sent back vulgar comments and the final rejection came from the moderator. To underscore the rejection of her application for membership, the moderator sent her a drawing of a skeleton with the middle finger extended.

Shared identify through eating disorder tips. Some sites promoted their identity though eating disorder tips, such as ways of losing weight quickly and shared behavior and weight loss ideas. They also promoted the use of special jewelry that promotes eating disorders (see box below).

Relationship to the eating disorder, longing for relationships online and inability to sustain relationships offline. Dr. Brotsky reported that website participants often identified themselves through the personification of the eating disorder. For example, one participant wrote, ‘Ana takes up all my free time but this doesn’t matter because I do everything with Ana.’ Another trend was that some members liked to join a group at a distance, without being seen and feeling safe online. Many members of the online communities indicated that they didn’t get support from others and thus turned to the website for online friendships and support.

Hope, support and recovery from the community. One of the positive signs that Dr. Brotsky experienced was the hopeful, supportive, and sometimes helpful comments from others online. When others learned that she was dealing with an eating disorder and leaving the site because she was pursuing treatment, they said, ‘This is a big step and I’m proud of you.’

Screening clients for pro-Ana Internet use

If a clinician suspects a client is actively using the pro-Ana network, Dr. Brotsky suggests first trying to determine how long the client has been a member of the website or websites and how often he or she participates. Learning if any pro-Ana friendships have emerged will also help explain why the progress in psychotherapy sessions may have been unusually slow.

One way to approach the client who uses the pro-Ana network is to suggest healthy alternatives, with websites such as Something Fishy, which also offers a good forum for discussing eating disorders. Dr. Brotsky also created her own website, United We Starve No More, to offer ideas about a healthy alterative lifestyle.

The Internet as an important adjunct to traditional therapy

The Internet offers a new and important adjunct to therapy that clinicians should be aware of, Kathleen Kingsbury told the audience. She noted that more than 98 million people use the Internet daily to get health information. And, as for eating disorders patients, she pointed out that the NEDA website recently had more than 5 million “hits” and more than 90,000 unique visitors during a single month.

A nonthreatening way to address eating disorders

The Internet offers a nonthreatening way for patients to keep in touch and to approach sensitive subjects they might not be able to address as easily in face to face sessions, Kingsbury said. Therapy online with no contact is not recommended for eating disorders patients, she stressed and certainly isn’t appropriate for high-risk patients or those with anorexia nervosa.

New technology is offering helpful ways for patients to communicate by using their portable computers, such as PDA units, where they can keep food logs or report episodes of anxiety and/depression. And, she added, one day patients may even be able to use virtual reality systems, much like the NASA astronauts do, to experience their bodies at different sizes.

As with the Internet overall, educational websites can be both helpful and unhealthy, she said. Kingsbury praised such sites as www.myselfhelp.com, a subscription online service that helps individuals learn about bulimia, binge eating and obesity, and that offers daily lessons, tools, exercises, and written tools. She also noted that telepsychiatry programs, like that developed by Dr. Jim Mitchell at the University of North Dakota, have proved to be very effective for persons in rural areas who have little access to health care.

A caveat: use the Internet with care

Before a clinician uses the Internet in a therapeutic program, he or she needs to consider several parameters, according to Kingsbury. Professional liability is one: some patients may be in an adjacent state and the clinician needs to be careful about licensure requirements. Also, technical problems can occur, and it is important to have procedures in place in case problems arise—for example, if the therapist is late.

Also, all information going to and from a client must be safeguarded, she stressed. An online system of encrypting information is very important, so the information cannot be decoded. There should be a system of password protection, she noted, especially if the client and family members are sharing a computer. The client should give informed consent before e-mail is exchanged, or at the least the therapist and client should talk about this—there should be a written policy about when and how the e-mail is going to be used, to avoid inadvertent breaches of confidentiality. Finally, Kingsbury said there is a great need for programs and software designed for loved ones and family members.