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.

 

 

 

Hot off the press is an excellent review article by The Redleaf Practice Director of Family Therapy (currently a Post Doctoral Fellow at University of California San Diego) and our own Research Fellow, Scott Griffiths and Daniel le Grange.
You can read it below or as a link here

I have stolen this (stolen, not adapted, just plain stolen) from wonderful ACT therapist Russ Harris.
It is a really nice way of incorporating mindfulness into daily life. 
The Mindful STOP 
We all know that mindfulness is ‘good for us’, just as we all know that exercise is ‘good for us’. However that doesn’t mean we need to do intensive mindfulness meditation for 40 minutes every day! In my workshops for coaches and therapists, I like to say, ‘If we want to motivate people to exercise more, we wouldn’t tell them, “You have to go to the gym for 40 minutes a day!” Rather, we’d say, “Every tiny little bit of exercise makes a difference. If you walk for five minutes at lunchtime, that’s better than not walking at all. If you walk up one flight of stairs instead of taking the lift, that’s better than not walking up any stairs. If you park your car in the parking space that’s furthest away from the supermarket, that’s better than parking in the closest one; even walking those few extra metres across the parking lot will make a difference.” ’

Sure, if you do exercise for 40 minutes a day, you’ll be healthier than if you do it for only 10 minutes a day – but even 5 minutes a day is a whole lot better than none at all! And so it is with mindfulness skills. Just like any skill we learn, the more we practice mindfulness, the better we get. So if you’re willing and able to do 30 or 40 minutes of daily mindfulness meditation (or similar formal mindfulness practices like yoga, or Tai Chi), that’s fantastic! Those are truly excellent practices for effectively developing your mindfulness skills. However, let’s be realistic here; many of us are unable or unwilling to make the time for this type of formal mindfulness practice on a daily basis. That’s just life!

However, that doesn’t mean we need to give up on the idea of regular mindfulness practice. It just means we need to find alternative ways of practicing our mindfulness skills throughout the day. That’s why in all my books you’ll find plenty of suggestions for quick, simple, easy ways to do this – e.g. having a mindful shower, mindfully brushing your teeth, mindfully patting the dog, mindfully hugging your loved ones, mindfully drinking your tea or coffee, mindfully ironing your shirts, mindfully tying your shoe laces, taking ten slow mindful breaths, etc. After all, one of the beautiful things about mindfulness is you can practice it anytime, anywhere, any activity. (To download a one-page handout/worksheet/tip-sheet on informal mindfulness practice, click here.)

Now here’s one especially useful, ultra-brief, and very simple mindfulness practice, that you can easily incorporate into your busy daily routine, no matter how pressed for time you are. I call it the mindful S.T.O.P. Here’s how it goes:

S – Slow down (slow down your breathing; or slowly press your feet into the floor; or slowly stretch your arms; or slowly press your fingertips together) 
T - Take note (with a sense of curiosity, notice your thoughts & feelings; notice what you can see and hear and touch and taste and smell; notice where you are and what you are doing) 
O - Open up (open up and make room for your thoughts & feelings, and allow them to freely flow through you; use any defusion or expansion skill you like) 
P - Pursue values (reconnect with your values, and let them guide whatever you do next)

The lovely thing about a mindful STOP is you can make it as short or as long as you like. You can zip through this in under thirty seconds – e.g. while you’re waiting at a red traffic light, or stuck in a supermarket queue, or waiting for your kids to come sit at to the dinner table – or you can stretch it out into a thirty minute formal meditation practice. I encourage you to try it out for yourself – not just once, but over and over and over again:Slow down; Take note; Open up; and Pursue your values. A regular mindful STOP works wonders.

This is what a patient (who gave me permission to write about this) said to me today.  Sandra suffers (in the truest sense of the word) from severe and enduring anorexia nervosa.  She has needed more than 10 admissions to a private hospital specialist unit.  She has needed numerous medical admissions in the public system for stabilisation.  She is the first to acknowledge that she is not the easiest person to treat, the anorexia fires viciously at treatment teams who try to stop purging or push for weight gain.
However, she is in love.  In love with a partner who is seeing her through this and in love with her young niece.  Sandra is beginning to understand the life she has lost and she wants to live now.  She also fears she will have none of these things. The anorexia will rob her of this.  She works hard with her therapist on looking at what she wants in her life and how the anorexia stops her from having these things.  She has told her therapist recently that she is willing to "take the plunge" and gain some weight and ensure medical safety.  She is trying hard at this as an outpatient, but needs more support.  She is becoming motivated to change, but not being able to is sapping this motivation.  We need to move quickly.
Sandra calls the private unit.  Their most experienced therapist is away.  The others do not want to take responsibility for her.  She is too sick to come to a private psychiatric hospital, or she might become sick in the unit.  She has not done well before and so, it is assumed, will not do well again.  "We will not take you until you have gained weight".  "She sits in groups and hasn't contributed"(fear does that to you sometimes) so "can't make use of the program". It is likely that the other private units will not take her for the same reasons. 

Sandra rings her therapist "they have sentenced me to death".  

Part of me can understand the hospitals thinking. I've been in the same position myself.  Your timing really sux though.  Maybe, just maybe, even a little maybe, Sandra was willing to make a small but significant shift. We will never know.

She is however actually medically stable according to those blood tests and ECG.  This of course means that a bed in the emergency bed isn't available to her.  One fears that this will change.

A call is put in to the regional unit.  The phone is answered quickly, the therapists details are taken.  The unit will get back to you.  With a long waiting list though, any systems motivation to move quickly wanes.  No call from the unit for 24 hours.  Sandra will agitate herself and call the unit.  Sandra knows there are some beds coming for the state. She is grateful for that. Maybe a bit late for her she feels.
The GP feels she is left with the sole medical responsibility for Sandra.  When she took over care there was the backing of a specialised treatment unit.  GP is understandably angry. 
 
Her family will hang in there with her. They don't get to say 'too hard, too sick'.

Her therapist will also hang in there and, guided by the evidence out there, will keep working to help build and recognise the life that is worth working at getting better for.