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Can On-line treatment be effective for treating patients with eating disorders?
Yes, but the patient should be well known by the therapist and the patient’s symptoms significantly reduced or eliminated prior to making the transition.
In the fall of 2014, I, for the most partclosed my NY psychotherapy practice in order to live full-time on a mountaintop home I purchased in Appalachia, North Carolina the year before. Since I had been winding down my NY practice for more than a year, there were only a few remaining patients who I believed would benefit from continued face-to-face treatment. These patients, for the most part, had active eating disorders or behavior or mood was not stable. On-going management of their symptoms was necessary, and the continuation of maintaining a safe and trusting relationship with a therapist was essential for long-term recovery. The best and most appropriate way I thought was to recommend that they remain in face to face therapy, despite the anticipated profound loss issues that accompany saying goodbye and making a transition to a new therapist – their and mine! (This is discussion for another blog post.)
There remained a few patients for whom terminating treatment in this day of technology could be avoided. Skype, I thought? It seemed antithetical to a practitioner who believed and continues to rely heavily on Object Relations and Attachment Theory in understanding why people turn to eating disorders and other self-harm or self-defeating behaviors. “How could trust be maximized with a patient if the patient and therapist were in separate places?”
I started reading the limited articles on On-line Therapy. Most of what I read appeared to be favorable, with appropriate caveats and instructions regarding establishment of protocols. In fact, an article that appeared in the NY Times on September 23, 2011, “When Your Therapist is Only a Click Away,” offered a balanced perspective regarding the benefits and limitations.
“Psychologists say certain conditions might be well-suited for treatment online, including agoraphobia, anxiety, depression, and obsessive-compulsive disorder,” wrote Jan Hoffman.
Treating mood and other Axis I conditions on-line?
Interestingly, in the past year since I have begun treating a few already established patients on line, I have found that those for whom anxiety is a significant component underlying their eating disorder, on-line therapy appears to be effective. In fact, I would say, very effective.
Eating Disorders tend to be highly correlated with Anxiety and/or Depression. When a patient presents with a moderate to high level of anxiety or depression, it is often difficult to initially engage or engagement takes a really long time. Sometimes, it is difficult for them to speak. Given the often immediacy of the eating disorder, I generally take an active stance, especially when a patient is struggling to utter words. Gone for me are the days when the therapist sits and waits, and waits and waits for the patient to start talking. Being in charge of the therapy in this manner is important; in fact, I think it can be incredibly effective in getting to the meat of the matter quickly. More importantly, being directive can facilitate the building of trust with the patient, especially if the therapist is a seasoned eating disorder clinician who can generally ask the right questions in a respectful and knowledgeable way, without making the patient feel interrogated.
What I was surprised to discover when I made the transition from face to face sessions to Skype, was that those patients who continued to struggle to get the words out, despite time well spent in my office, suddenly were speaking fluidly and were more open and reflective in their responses and reactions via Skype.
The computer provides buffers as it creates a barrier; patient and therapist are not in the same room. However, eye-to-eye contact is enhanced perhaps because it is easier and more ‘natural’ as it is the camera that the patient is looking in to, not the eyes of a person. It is possible that anxiety surrounding proximity and relational closeness is thereby reduced. Not surprisingly, is that when patients are seen physically in my office, as I continue to travel to NY once a month to meet with them in person, they are able to maintain conversation and eye contact. Is it possible that the computer is actually a tool or vehicle to ultimately reduce anxiety and support relational ease?
When is it possible to treat eating disorders on-line?
The guiding rule for me is never have an initial consultation with anyone on-line, and certainly never treat a new patient with an eating disorder or one whose symptoms need to be regularly managed. My personal requirement is not to treat anyone on-line unless I have an established relationship with the patient and at least a working rapport with a family member when working with a teenager or young adult.
The risks to not knowing your patient through time spent face to face mostly center on the therapist being less able to identify non-verbal cues plus the inability to establish trust, which happens, reliably by physically spending time. Remember safety and trust are necessary for all patients; it is paramount for eating disorder patients. It is this relational trust that will allow a patient to report honestly and openly about their symptoms or regression in behavior. I.E. It is difficult to see whether a patient has lost weight. Relying on the patient to state this implies that the patient trusts you to not only help, but also to not judge or become an alarmist.
If a patient is well along in recovery, but there is still some concern about symptoms or regression, working in conjunction with a nutritionist who can physically meet with the patient can offer not only support, but also provide the necessary reality checks.
I also strongly advocate seeing the patient in your office physically from time to time, perhaps every few weeks or monthly, if possible.
Also, know what laws apply to your particular state. There are several articles that detail some risk/benefit analysis of on-line treatment, including HIPPA and insurance billing matters (see October 10, 2014 GoodTherapy.org.) There is also some material available for helping mental health practitioners set up on-line practices. (See Kraus & Strickler. Online Counseling: A handbook for mental health professionals. 2011.)
Time and more extensive research are necessary in determining efficacy of on-line treatment in general and certainly in providing on-line treatment for eating disorders.
“Online psychotherapy has practical advantages in some situations, and as a treatment modality it does not appear bogus or inherently harmful,” writes Steven Reidbord, MD for Psychology Today (2013.) “It would be interesting to compare telephone and video therapy in a research context, to see whether the visual channel confers additional useful information, and whether it enhances or detracts from the therapeutic alliance. As with most technological innovations, online therapy also introduces new pitfalls and deepens old ones, so it is best not to choose it merely for its novelty or expedience. Face to face treatment is still the gold standard,” states Reidbord.
Best,
Judy Scheel, Ph.D., LCSW
