Using text messaging in the treatment of eating disorders

 

Abstract
Hazelwood, A. (2008) Using text messaging in the treatment of eating disorders. Nursing Times; 104: 40, 28–29.

New technologies for communicating with patients can open up new treatment possibilities. This article describes the use of mobile phone text messaging as a therapeutic intervention in the treatment of eating disorders.

In text messaging a person can conceal themselves and – very significantly in the context of eating disorders – the body does not show. The exchange does not have to be instantaneous and is not face to face.

This article outlines the use of mobile phone texting, alongside therapy and other nursing interventions, as an effective tool to help clients communicate their thoughts and feelings in a safer and freer way.

Author
Amanda-Jane Hazelwood, MSc, MA, PGDip, BSc, DipHEd, RMN, is consultant nurse, eating disorders service, South Staffordshire and Shropshire Healthcare NHS Foundation Trust.

Introduction

For more than three years I have been using texting as an integral part of therapy.

It began when one of my clients was placed in an inpatient service out of the county to treat long-term anorexia nervosa. We began using text messaging as a way of maintaining therapeutic contact. I soon came to realise that, for this patient, texting was an easier and safer way to communicate and forced her, unknowingly, to be more succinct in her communications.

Over the following year, I introduced this concept to all clients on my caseload.

Text messaging challenges three of the traditional premises for therapeutic interaction: visible contact; talking; and synchronous – 'real time' – interaction.

Literature review

A review of the literature was undertaken and it revealed minimal research on the specific topic of text messaging with patients with eating disorders.

The review found only two studies. The first was a pilot study on using texting with patients with bulimia (Bauer et al, 2003).

This study was carried out in a German hospital and showed how text messaging was used in the post-treatment phase of bulimia. The second study was a feasibility pilot in the same area (Robinson et al, 2006).

Both studies featured a computer-generated response when patients texted rather than a dedicated human one and both focused on aftercare rather than the treatment phase.

My work differs from these as it offers a human response and occurs during the care process.

Using text messaging

In my texting work with clients, I do not usually initiate the messaging.

Clients can text if they want or need to between 8am and 6pm Monday to Friday. They can also text after that time but would not receive a response until the next morning unless the text highlighted an emergency situation.

The opportunity to send a text message to me at any time seems to create a comforting feeling that their therapist is always there. This can often ease feelings of separation and allow clients to articulate their thoughts and feelings immediately, during or after an important event, rather than having to wait for the next appointment.

Furthermore, this asynchronous communication does not require an instant response to what a client has said. As a therapist I have the time to think, evaluate and compose the reply, allowing interventions to be more carefully planned.

Irrespective of age, all clients use this medium and even those who struggled initially with text messaging have overcome this to be able to benefit from the service. This demonstrates that using this medium can be learnt.

One older female client with bulimia decided to ask her son to teach her to text as she did not want to miss out on this experience. Within a few weeks she was proficient at texting and has found it a great source of comfort and help in between sessions.

She recently said: 'When you first mentioned using it [texting], I did not see how it could help me but since I have been using it, I feel I can cope better as I know if I struggle you are only a text away.'

This client also explained how she tends to save significant messages so she can revisit them if she is feeling down and they can motivate or comfort her again.

This is an interesting aspect of the service, as the spoken word can be lost but a text message can be revisited and reused repeatedly.

Benefits of texting

Clients who do not feel confident using their verbal skills have said they prefer text messaging to face-to-face contact.

Texting has facilitated the development of intimacy and trust in the therapeutic relationship. For most clients, texting has encouraged more self-expression and self-reflection than face-to-face communication.

For clients who struggle with social anxiety or issues of guilt and shame about their eating disorder, the texting medium has helped them as they cannot be 'seen'.

Recently, three clients were feeling actively suicidal and all three alerted me to their crisis via text. For two, I managed their suicidality via text messaging and intervened at regular intervals until their mood lifted. For one, I became so concerned I called the local crisis team and read the text messages to demonstrate the client's level of suicidality.

I was also able to maintain enough contact with this client via text to give the police valuable time to go to her house and intervene to stop her taking an overdose.

Saved messages have been an accurate and rich source of information for reliving and re-evaluating the therapeutic relationship, as well as providing continuity within it.

Clients have said that texting has helped them say exactly what they want to say, as they are afforded time to think and construct their message, revisit it and check it before sending it. It also allows me to do the same.

The overall visual construction of a text message (frequency of line breaks, size of paragraphs, abbreviated words) helps reveal a client's mood and state of mind, and any change in that style or format shows their mood/state of mind has also changed.

As my work has progressed I have used text messages (both sent and received) in therapy sessions to explore, reflect and learn from the transactions.

Text content

Clients' ability to express themselves via texting seems to vary greatly, often reflecting the nature of their eating disorder.

Concrete, emotional and abstract expression, complexity of vocabulary and sentence structure, and organisation and flow of thought all reflect a client's cognitive/personality style and influence how they react to me.

Clients with anorexia are perfectionist and strive for well-organised and intellectualised messages with sparse emotion and few, if any, spelling or grammatical errors. Clients with bulimia tend to write longer messages than those with anorexia and texts can be disorganised and dashed off quickly with emotional phrases.

Often clients will use 'emoticons' like the smiley, winky and frown faces. These are seemingly simple character sets that nevertheless seem to capture subtle nuances of meaning and emotion.

Parenthetical expressions can often convey body language or 'subvocal' thoughts and feelings (sigh, feeling unsure and so on). This is an intentional effort by clients to convey some underlying mood or state of mind.

Conclusion

This article highlights the importance of understanding and using mobile phone texting in clinical practice and of its possible benefits in healthcare.

Using texting in my clinical work has led me to conduct research in this area.

Clients may find texting a more productive and helpful way of discussing their issues than face-to-face contact. Or it may be the case that texting in addition to face-to-face contact makes therapy and/or interventions generally more effective.

References

Bauer, S. et al (2003) The use of text messaging in the aftercare of patients with bulimia nervosa. European Eating Disorders Review; 11: 3, 279–290.

Burney, J., Irwin, H.J. (2000) Shame and guilt in women with eating-disorder symptomology. Journal of Clinical Psychology; 56: 51–61.

Gilbert, P.G (2005) Compassion: Conceptualisations, Research and Use in Psychotherapy. London: Routledge.

Joinson, A. (1998) Causes and implications of disinherited behaviour on the internet. In: Gackenbach, J. (ed) Psychology on the Internet. Orlando, FL: Academic Press.

Robinson, S. et al (2006) Aftercare intervention through text messaging in the treatment of bulimia nervosa – feasibility pilot. International Journal of Eating Disorders; 39: 8, 633–638.

Utz, S. (2000) Social information processing in MUDs: the development of friendships in virtual worlds. Journal of Online Behavior; 1: 1.