Online Therapy for Eating Disorders

Online Therapy for Eating Disorders

Luis Alvarez, DigitalVision, Getty Images  

The COVID-19 pandemic has forced many changes upon our way of life in 2020. In the realm of outpatient mental health, one of the most sudden shifts was the abrupt change in the delivery of treatment, including that for individuals with eating disorders.

Almost all outpatient psychotherapy and nutrition therapy office visits have been replaced by telehealth sessions delivered virtually. This is really an acceleration of an existing trend—telehealth been around for almost as long as the telephone, albeit not at its present level of popularity.

As a client who may be increasingly offered telehealth sessions, it is important for you to be informed. If you have never had therapy online you may have a lot of questions. You may wonder whether it will be as effective, whether it will be confidential, whether you will be able to connect with a therapist, or whether you can truly open up to someone over the computer. These worries are understandable and will be addressed below. You may be reassured to learn that online therapy can work well and offers many advantages.

What Is Telehealth?

Telehealth is the delivery of services remotely using telecommunications technology. This sweeping term has in the past been used to refer to therapy treatments delivered via videoconferencing, telephone, and other technologies such as text and email.

The use of technology to deliver health care at a distance has a long history with the first telephone “house call” in 1879. The use of videoconferencing in psychiatry began in the 1950s when the Nebraska Psychiatric Institute began using early video conferencing to provide various treatments in 1959. Telehealth has become much more common since 2000 with the arrival of higher speed internet and better video conferencing technologies.

For the purposes of this article, we will restrict the term to mean treatment delivered in the format of live video sessions conducted via a computer or smartphone, such that the therapist and provider can “see” each other face-to-face. Other terms sometimes used include online therapy, teletherapy, telemedicine, video mental health, or video therapy.

Telehealth requires the patient and the provider to each have a video device (a computer or a smartphone) that is connected over the internet or a cellular data network. Clinicians may use a variety of telehealth platforms specifically designed for health providers.

These services are more secure than traditional apps—in the US most providers have to comply with the Health Insurance Portability and Accountability Act (HIPAA). Common platforms used by providers include VSee, Doxy, and Zoom (usually a special version for healthcare providers).

Does Telehealth Work?

Research has shown that telehealth has been successfully applied with many different populations, including children, adolescents, adults, older adults, ethnically diverse populations, veterans, and active-duty military service members, in treating the following disorders:

  • Anxiety disorders
  • Bipolar disorder
  • Depression
  • Obsessive-compulsive disorder
  • Panic disorder
  • Posttraumatic stress disorder
  • Substance abuse

Research indicates that teletherapy provides substantially similar results to therapy delivered in person.

Telehealth offers many advantages. Most relevant in the context of today’s pandemic, it reduces exposure to germs and hence lowers your risk of contracting the coronavirus. Telehealth allows you to receive therapy from the safety and comfort of your own home. It eliminates the time spent traveling to sessions. Due to its greater flexibility, there are situations in which it can allow for fewer interruptions in treatment.

Telehealth for Eating Disorders

The two leading evidence-based psychotherapy treatments for eating disorders—Cognitive-Behavioral Therapy (CBT) for adults and Family-Based Treatment (FBT) for adolescents—are both well-suited to be provided over telehealth. CBT is a type of therapy that can easily occur over video calls. It focuses on identifying negative thinking and emphasizes the importance of the patient making behavioral changes and working on specific tasks between sessions to produce this change. FBT is a therapy that enlists the entire family to help change the behaviors of a person with an eating disorder.

There are relatively few studies of telehealth treatment for eating disorders. A research study on CBT for adults with eating disorders delivered over telehealth showed that it was effective at reducing binge eating and purging and had outcomes “roughly equivalent” to CBT delivered in-person. Patients in the study found online therapy acceptable. Patients in the online condition also reported establishing as strong an alliance with their therapist as did the patients who had face-to-face therapy.

There is also preliminary support for the delivery of FBT via telehealth. One study examining FBT for adolescents delivered over the internet found that patients improved and parents considered the treatment acceptable. FBT online sessions can easily be conducted with various family members gathered around the video screen. Even family meals, a standard part of treatment in which families typically bring a picnic meal to the therapist’s office, can be conducted online.

Nutritional counseling is also well suited to being conducted by video—this is sometimes referred to as telenutrition. In a 2015 survey of five thousand members of the Academy of Nutrition and Dietetics, results indicated that 30% used telehealth to practice nutrition with their clients. It is likely that this number is much higher now.

Legal and Financial Considerations

In the United States, there are legal and financial considerations related to telehealth. Most states consider that psychotherapy occurs where the patient is located at the time of the session, regardless of where they reside.

Since each state has its own licensing board, many therapists can only practice when patients are physically located in a state in which they are licensed and may not, except in special circumstances, be able to provide therapy to patients physically located in another state over telehealth. This is only partially true for registered dietitian nutritionists (RDNs); they have some greater flexibility seeing patients in other states.

As of 2018, a number of US states have adopted telehealth parity laws that require insurance companies to cover teletherapy sessions at the same rate as in-person treatment. However, not every state has such a law, and even within those that do some insurance companies carve out their telehealth benefits to different networks that only provide telehealth.

Thus, although telehealth may be a covered benefit within an insurance plan, eating disorder specialized care may not be available.

To complicate things further, after the World Health Organization declaration of the COVID-19 pandemic, several insurers made temporary exceptions to payment restrictions and several states eased restrictions on patients seeing out-of-state therapists. It is not yet clear how long these relaxations will remain in effect. But one thing is clear: telehealth is acceptable to many people and will increasingly be a treatment option for many with eating disorders and other mental health problems. It is likely that telehealth is here to stay as a viable treatment modality.

What Do I Need to Know if I Want to Use Telehealth?

Make sure you have a private, safe, and quiet location from where to have your session. Do not attempt to have a session while you are driving. You will need to have a computer or smartphone with a camera and microphone. Using earphones helps to protect your privacy from people who may be nearby.

Try to ensure you have a good internet connection. Ensuring virus protection software and other software is up to date offers further privacy protection. It is recommended that you test your technology before an initial session and provide emergency information to your therapist in the event that your connection is disrupted during a crisis.

You should turn off alerts on your phone or computer so they do not interrupt the session. You may also want to turn off “assistant” devices such as Alexa, Siri, and Google Home so they do not record and disseminate confidential information.

Telehealth may be challenging for those who have little privacy at home or who are technologically challenged. Some patients, particularly those with eating disorders, may become preoccupied with the preview image of themselves. If you are one of these, it is recommended you “hide your self-view,” which most platforms have as an option.

Medical monitoring and weighing obviously become more difficult when sessions only occur virtually. Providers will need to let you know how they wish to handle it. Some patients may need to have periodic in-person checks of vitals or weigh themselves at home.

A Word From Verywell

Teletherapy seems to be well-accepted and patients are generally satisfied with this delivery method. Although you may miss aspects of seeing your provider in person you will likely find that you can still establish a strong therapeutic alliance and work on overcoming your eating disorder from the comfort of your own home.

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  1. Waller, Glenn, Matthew Pugh, Sandra Mulkens, Elana Moore, Victoria A. Mountford, Jacqueline Carter, Amy Wicksteed, et al. n.d. “Cognitive-Behavioral Therapy in the Time of Coronavirus: Clinician Tips for Working with Eating Disorders via Telehealth When Face-to-Face Meetings Are Not Possible.” International Journal of Eating Disorders n/a (n/a).

  2. Mitchell JE, Crosby RD, Wonderlich SA, et al. A randomized trial comparing the efficacy of cognitive-behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-faceBehav Res Ther. 2008;46(5):581‐592. doi:10.1016/j.brat.2008.02.004

  3. Anderson, Kristen E., Catherine E. Byrne, Ross D. Crosby, and Daniel Le Grange. 2017. “Utilizing Telehealth to Deliver Family-Based Treatment for Adolescent Anorexia Nervosa.” International Journal of Eating Disorders 50 (10): 1235–38. https://doi.org/10.1002/eat.22759.

  4. Peregrin, Tony. 2019. “Telehealth Is Transforming Health Care: What You Need to Know to Practice Telenutrition.” Journal of the Academy of Nutrition and Dietetics 119 (11): 1916–20. https://doi.org/10.1016/j.jand.2019.07.020.

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