Friends or Foes? The internet and eating disorders
By Hannah J. Hopkins, MSW
As the internet and social media have permeated our lives, researchers have sought to investigate the impact that web usage has on mental health. Perhaps unsurprising given the variety of content and users present on the internet, results have been complicated. Understanding these results is critical for health professionals, individuals with or at risk for eating disorders, as well as friends and loved ones to understand. This article provides a review of the risks and benefits of the internet and a discussion of how to maximize benefits and mitigate risks of internet usage.
Foe: negative peer influences and misinformation
For people struggling with an eating disorder (ED), the internet is ripe with triggering images, dieting/weight loss tips, and inaccurate information. One particularly damaging corner of the internet are online communities that promote EDs, commonly known as “pro-ana” for pro-anorexia, “pro-mia” for pro-bulimia, “fitspiration”, “thinspiration”, or “thintention”. These sites are often blog-based. The blog structure allows users to document their weight loss, post pictures to “inspire” others to remain adherent to their weight loss goals, and interact with one another via a community board. Many users refer to their ED in the first person (“ana” for anorexia, “mia” for bulimia) and advocate EDs as a lifestyle choice rather than a disease. The majority of individuals who create and visit these sites are young women ages 18 to 25, although some research suggests that the average age for viewers is younger (13-15 years old). Studies have found that viewing these websites for several minutes alone can cause an increase in dieting and body dissatisfaction and lower self-esteem. These results are true even for individuals who accidentally or infrequently view the content. Where most people don’t feel comfortable promoting EDs in public due to fear of social backlash, the internet provides the anonymity and impersonality necessary for “pro-ana” communities and the like to flourish.
Although some people may argue that this risk is not of great concern for those who don’t actively seek out pro-ED content, research says differently. Many popular search engines, like Google, and video-content websites, such as YouTube, create search result lists based on the popularity of each result. This practice increases the chances that someone seeking support will encounter bad information or even material promoting EDs. One study found that almost 30% of the results retrieved in a YouTube search for the word “anorexia” were pro-anorexia material, meaning that these results promoted anorexia rather than educating viewers about this disorder. Given what we know about the negative effects that pro-ED content has on mental health, this is a particularly concerning trend.
Another risk posed by the internet is the potential for exposure to misinformation. This is particularly critical for anyone who uses the internet as their chief source of information. One research study concluded that most of the information on popular mental illness education websites was either outdated, unclear, contradictory, or factually incorrect. Another study reviewed results from 79 scholarly articles looking at the quality of health information on the web. Of those 79 research papers, 55 concluded that the internet provides poor quality health information. The abundance of misinformation related to health, mental illness, and EDs on the internet is a major point of concern.
Friend: bringing support and knowledge from the therapist’s couch to yours
Although the internet poses significant risk for individuals with EDs, it is also important to recognize the internet as an unparalleled opportunity for intervention. The new fields of “e-therapy” is rapidly growing in Western societies. E-therapies are services provided by qualified professionals using the internet (or phone-based apps) for the purpose of treatment. Using the internet as the medium for therapy allows individuals to stay anonymous, seek treatment from anywhere in the world (with an internet connection), and access treatment at a fraction of the cost as traditional, face-to-face therapies. These opportunities are particularly compelling for EDs. Studies have shown that less than a quarter of individuals with an ED actually seek treatment. Of those who do seek treatment, an even smaller percentage receive it due to barriers such as insurance coverage and location. The 75% of individuals with an ED who do not seek treatment report fear of negative stigma, shame and guilt, and lack of financial resources as reasons they did not seek treatment. Given that the internet offers people the opportunity to remain anonymous, keep their treatment private from others, and access it for little to no cost, e-therapies for EDs may prove instrumental in reaching a larger proportion of individuals who need treatment.
Not only does the internet bring therapy to the consumer, it also brings support in the form of online support groups. Unlike e-therapies, support groups are designed to promote community amongst people struggling with EDs. While these support groups may be monitored by professionals to screen for inaccurate information or inappropriate content, online support groups are not designed to be therapy. Instead, they offer a chance for individuals experiencing similar challenges to swap experiences and encouragement. Similar to e-therapies, online support groups allow users to access these services for no or low cost and remain anonymous while doing so. The importance of anonymity is particularly crucial for the ED community. Studies have found that individuals in support groups for EDs are less likely to participate when they can see their group members. The lack of physical interaction between participants in online support groups appears to boost participation and therefore increase positive results. Most people who have an ED feel very lonely, misunderstood, and ashamed of their disorder. Breaking that cycle with anonymous, low-cost, 24/7 accessible therapy and support forums is a benefit that only the internet can provide.
Where do we go from here?
Wading through the controversy surrounding the internet and its impact on mental health can be exhausting. While some benefits are clearly present, many people wonder if those benefits are worth the risks. Thankfully, there are a few steps that professionals and the public alike can take in order to make the internet their friend in combatting EDs. To combat the spread of misinformation, health professionals and educators should reinforce the importance of using scholarly, evidence-based information to make decisions regarding personal health. Consumers should be consistently reminded of what constitutes a “scholarly” source and taught how to recognize misinformation. Teaching web users this skill is particularly critical for the less computer-literate and for those who spend a significant amount of time on the computer. Additionally, major search engines should be encouraged to adjust their search algorithms to feature verified sources whose information can be trusted for accuracy instead of basing results on popularity alone. Online support forums should also be managed by professionals; this allows for inaccurate information (even if posted with the best intentions) to be screened out. By promoting the availability of current and trusted health information, individuals seeking to understand mental health and EDs can feel more comfortable using the internet as a resource.
Policing online pro-ED communities poses more challenging. Policy makers, healthcare professionals, and the public have to balance the right to free speech with the growing awareness for mental health concerns when approaching online communities. Some social media platforms have taken steps towards regulating and monitoring pro-ED pages. In 2012, Tumblr and Pinterest – two popular and widely used social media sites/apps – announced their plans to prohibit content that promotes EDs. Pinterest now shows a message with a link to the National EDs Association (NEDA) website if a user searches for pro-ED content. Facebook has instituted a similar safeguard where community members can report their concerns about a user who they believe is experiencing mental health problems. To date, social media sites have been the leaders in limiting exposure to content that promotes damaging behaviors. The efficacy, legality, and wider applicability of these policies continues to be a topic of conversation and controversy.
As e-therapies and online support forums become more available, websites should encourage users flagged as “at risk” to access these resources. Reducing the barriers that many people confront when starting treatment – notably financial limitations, guilt and fear – is a crucial step to involving people in the services they need. Online interventions could serve as a viable first contact for people at risk because they do minimize those initial barriers to a much greater degree than face-to-face intervention. Accordingly, more research is needed to refine e-therapies for efficacy and to understand what makes certain individuals a better fit for these alternative treatments.
About the author:
Hannah J. Hopkins, MSW, currently works as a clinician in a substance abuse treatment facility and serves on the editorial board for the Journal of Clinical Sport Psychology. She graduated with her masters in social work from the University of North Carolina Wilmington and with her bachelors in psychology from Duke University. Hannah has been instrumentally involved with several research projects in the field of eating disorders, including studying dysfunctional relationships in anorexia nervosa, investigating picky eating in young children, and understanding the concept of rumination in binge eating disorder. Hannah’s primary research interests are bingeing behaviors and the overlap between substance abuse and eating disorders. In her free time, she enjoys being outside, spending time with her guinea pigs, and reading fantasy novels.
Aardoom, Jiska J., Alexandra E. Dingemans, Philip Spinhoven, and Eric F. Van Furth. “Treating Eating Disorders over the Internet: A Systematic Review and Future Research Directions.” International Journal of Eating Disorders 46, no. 6 (2013): 539–552. doi: 10.1002/eat.22135.
Bardone-Cone, Anna M., and Kamila M. Cass. “What Does Viewing a Pro-Anorexia Website Do? An Experimental Examination of Website Exposure and Moderating Effects.” International Journal of Eating Disorders 40, no. 6 (2007): 537–548. doi: 10.1002/eat.20396.
Homewood, Judi, and Maral Melkonian. “What Factors Account for Internalisation of the Content of Pro-Ana Websites?” Journal of Neurology Neurosurgery & Psychiatry 86, no. 9 (2015): e3. doi: 10.1136/jnnp-2015-311750.37.
Levine, Michael P., and Sarah K. Murnen. “‘Everybody Knows That Mass Media Are/are Not [Pick One] a Cause of Eating Disorders’: A Critical Review of Evidence for a Causal Link between Media, Negative Body Image and Disordered Eating in Females.” Journal of Social and Clinical Psychology 28, no. 1 (2009): 9–42. doi: 10.1521/jscp.2009.28.1.9.
Loucas, Christina E., Christopher G. Fairburn, Craig Whittington, Mary E. Pennant, Sarah Stockton, and Tim Kendall. “E-Therapy in the Treatment and Prevention of Eating Disorders: A Systematic Review and Meta-Analysis.” Behaviour Research and Therapy63 (2014): 122–131. doi: 10.1016/j.brat.2014.09.011.
McCormack, Abby and Neil S. Coulson. “Individuals with Eating Disorders and the Use of Online Support Groups as a Form of Social Support.” Computers, Informatics, Nursing28, no. 1 (2010): 12-19. doi: 10.1097/NCN.0b013e3181c04b06.
Pheylan, Hayley. “Pinterest Bans ‘Thinsporation’ and Pro-Anorexia Content.” Fashionista (2012). Retrieved from “https://fashionista.com/2012/03/pinterest-bans-thinsporation-and-pro-anorexic-content”.
Reavley, Nicola J., and Anthony F. Jorm. “The Quality of Mental Disorder Information Websites: A Review.” Patient Education and Counseling85, no. 2 (2011): e16–e25. doi: 10.1016/j.pec.2010.10.015.
Syed-Abdul, Shabbir, Luis Fernandez-Luque, Wen-Shan Jian, Yu-Chuan Li, Steven Crain, Min-Huei Hsu, Yao-Chin Wang, Dojsuren Khandregzen, Enkhzaya Chuluunbaatar, Phung Anh Nguyen, and Der-Ming Loiu. “Misleading Health-Related Information Promoted through Video-Based Social Media: Anorexia on YouTube.” Journal of Medical Internet Research15, no. 2 (2013): e30. doi: 10.2196/jmir.2237.