An article coauthored by the influential Christopher Fairburn has stated that there is little evidence that etherapy is helpful in the treatment of eating disorders. Etherapy was defined as online self help programs with either little or no clinician intervention or app based interventions. Interestingly there was no data on app-based interventions. Etherapy, as reviewed in this study, did not include therapy sessions delivered by video conferencing (such as Skype) or guided self-help interventions where there is an active clinician component.
The results of the Loucas study found only 20 studies that met strict inclusion criteria, which was based on criteria used in medical research. The use of inclusion criteria is important as it reduces the impact of results of weaker studies.
Only six of the studies involved therapy treatments and one relapse prevention study (etherapy post hospital). These studies were primarily based around a CBT intervention. When compared to a waitlist control group etherapy did show some modest benefit in binge eating (especially in Binge Eating Disorder) and purging behaviour. However confidence in the effect size was low.
This study has different results from two other previous reviews which were more positive regarding the role of etherapy. This is largely due to the stricter inclusion criteria applied in the Loucas study.
It is also a different results to other disorders, where internet delivered therapies appears to be more helpful.
Investigation of the efficacy of etherapy is important. One of the dilemmas facing the field of eating disorders is the difficulty of people to access evidence based treatments. The Internet is one way of addressing this. Otherwise we have fairly good treatments available only to those that can attend face-to-face therapy during office hours. The cost of treatment is also an impediment that etherapy will address. Taking an evidence-based approach to etherapy is also important as some websites will claim that etherapy (ie the package that they provide) is an effective treatment. This is a claim that needs to be proven to protect those suffering from an eating disorder. If the etherapy provided is not as helpful as face-to-face therapy, engaging in etherapy may be stopping engagement in a more helpful treatment modality.
One of the problems with the way current etherapy is delivered is that it is in a self help format. There seems to be little difference between the content of self help books and most etherapy programs apart from the mode of delivery. Evidence based therapies are often accused (usually by people who don’t practice them) as mechanistic and minimizing the role of the clinician. I don’t think that this is the case when they are delivered well. Indeed, therapist should be trained to use the manuals in a flexible way focusing on the individual needs of the patient. Etherapy needs to involve to become more interactive and delivered in a flexible manner with the specific needs of the patient in mind.
Of course, as a living and breathing therapist I am glad there is still a role for the therapist and a therapeutic relationship, which is a nice way of saying I am biased here. I have found that a way to disseminate evidence-based therapy to regional areas is via Skype video. One study (Mitchell et al 2008) compared face-to-face therapy with Skype delivered therapy and there was no significant difference in outcome or drop out rate. Given the difficulties in disseminating therapist training, Skype (or similar solutions) is a possible solution to disseminating evidence-based treatments.
As always, comments or questions are welcome.
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