A Web-based Treatment Program Offers Intensive Therapeutic Contact

Dutch adults with eating disorders
go online, with follow-up.

Reprinted from Eating Disorders Review
May/June Volume 24, Number 3
©2013 Gürze Books

Twenty years after the Internet first became available to the general public, Internet-based treatment programs for patients with eating disorders are proliferating and producing positive results. One pilot program in the Netherlands adds intensive therapeutic contact for participants.

Elke D ter Huurne and Cor A. J. DeJong, MD, PhD, and colleagues recently tested a web-based treatment program that provided intensive personalized communication between eating disorder patients and individual therapists (J Med Internet Res. 2013;15:e12).  The Dutch researchers developed the program because few Dutch eating disorder patients are treated by mental health care professionals. The study used a pre- and post design with 6-week and 6-month follow-ups to measure eating disorder psychopathology, body dissatisfaction, body mass index (BMI, kg/m2), physical and mental health, and quality of life. Participants included 165 adult patients with eating disorders: 115 with eating disorder not otherwise specified (EDNOS), 24 patients with purging-type bulimia nervosa (BN), and 24 patients with non-purging type BN. The web site was written for general audiences and all eating disorder diagnostic groups, to reach a broad cross-section of the public.

A two-part program using multiple techniques

The final study group included 165 adults who visited the website and signed up for the web-based treatment program between January and December 31, 2010.  The structured, two-part treatment program used cognitive behavioral therapy (CBT) and motivation interviewing, as well as psychoeducation, cognitive restructuring, self-control techniques and exposure techniques.  The goals of the online program were to improve eating disorder psychopathology and to reduce body dissatisfaction. The treatment program lasted about 15 weeks, and patients visited the web site once or twice a week, keeping regular contact with their therapist. The therapist always responded within 3 working days, and monitored the progress of the treatment program. Participants could log in at any time they wished and had a personal space and dossier, so they could have access to messages sent by the therapist. Patients also had the option to request a face to face meeting or direct telephone contact with the therapist.

The first part of the web-based treatment program included 4 assignments and at least 7 contacts with a therapist, with a focus on an analysis of the patient’s eating behavior. Patients registered their daily eating behaviors, analyzed their eating situations, and described the advantages and disadvantages of their eating problems. At the end of part 1, patients received personal advice from the therapist, who had a bachelor’s degree in nursing or social work or a Masters degree in psychology. All therapists had also successfully completed an intensive training program before the intervention began. The therapists also had access to expert advice from a multidisciplinary treatment team, including psychologists, a dietitian, and supervisors.

Part 2 of the online program began with setting goals for eating behavior, exercising patterns, self-weighing, and compensatory behaviors.  Participants had 6 assignments and at least 14 contacts geared to helping the patient reach goals and make desired behavioral changes. At baseline and at the 6-week and 6-month follow-ups, participants completed a series of online self-report questionnaires and reported their satisfaction with the program.

Most found the program to be effective

Slightly more than half of the original participants (86, or 52%) completed the online program. Most reported that they found the web-based treatment to be an effective method for treating their eating disorders and nearly all stated that they would recommend the program to others. A key factor tied to patient satisfaction was the support of the therapist, according to the participants.

The web-based treatment program successfully changed the eating disorder psychopathology in patients with eating disorders, and the improvement was sustained at 6-week and 6-month follow-up. The authors did not find any significant improvement in BMI for participants who were underweight (defined as a BMI <18.5 kg/m2) or overweight (BMI= 25-30 kg/m2).

The authors did point out that one weakness of their program was the 46% attrition rate.  Those who completed the program and those who did not differed significantly on several baseline characteristics. Baseline physical and mental health as well as participants’ degree of body satisfaction were markers of who would successfully use and complete the web-based treatment program.  Thus, the authors view the web-based treatment program as an important and accessible first step in stepped-care treatment. 

The authors are continuing their study with a randomized controlled trial to provide more concrete evidence of the effects of the online intervention.

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