Social Networking: Intervening to Intercept Eating Disorders

An Interview with Dr. Kimberly Dennis, Medical Director, Timberline Knolls Residential Treatment Center, Chicago

 

Through the Internet teenagers today literally have the world at their fingertips. Unfortunately, for some teens, this instant access to multiple websites may place them at risk for developing an eating disorder. In a recent study from the University of Haifa, Israel (in press), researchers found that the more time adolescent girls spend in front of Facebook, the more apt they are to develop an eating disorder.

And, when Dr. Rebecka Peebles of Stanford University and colleagues evaluated 180 pro-eating disorders sites, they found that most of the sites recognized eating disorders as a disease, and more than a third included recovery information. However, about a fourth of the sites earned high perceived-harm scores. In an earlier study, Dr. Peebles found that eating-disorders patients who viewed pro-ana (pro-anorexia nervosa) sites and pro-mia (pro-bulimia nervosa) sites were ill longer and spent less time on schoolwork. And even those who viewed pro-recovery sites were admitted to the hospital more often than were those who never visited such sites. Of course, this doesn’t necessarily imply a causal relationship. This association might simply reflect that those spending more time on these sites were more seriously ill and more involved with eating disorders to start with.

Dr. Kimberly Dennis, Medical Director of Timberline Knolls, a private residential treatment center for eating disorders and substance abuse in suburban Chicago, has a particular interest in the Israeli Internet study because she and her staff have seen the same patterns among their young patients. EDR recently spoke with Dr. Dennis to learn more about how her center helps patients handle the negative aspects of social networking. Timberline Knolls treats only female patients over the age of 12.

Dr. Dennis reports that from a third to a half of their young adult patients are actively using social networking sites to support their eating disorders, and many commonly visit pro-ana and pro-mia websites. This pattern is much less common in older adult women. According to Dr. Dennis, dhat during the past five years there has been an explosion of people spending a disproportionate amount of time connecting through the social networks rather than spending face-to-face time with friends and family. One pattern that Dr. Dennis has seen is that “Teens and adults alike are becoming over-connected electronically and under-connected to the people around them, and while social media can be excellent for helping teens stay connected with friends and family when used in a balanced way, it has a number of drawbacks.” Like any tool, she adds, “it can be abused.”

Dr. Dennis and her colleagues are finding that newly admitted patients have been using the Internet as a way to build on the isolation that accompanies their eating disorder because it is safer than dealing with others face to face or even voice to voice. For other patients, social networking sites act as a way to solve problems through an illusion of control. Dr. Dennis adds that there are ways to use social networking to support recovery efforts; it’s quite a different matter when patients come to the treatment center.

What Can Clinicians Do?

Dr. Dennis advises, “With any new patient, always specifically ask about the client’s degree of social networking and use of the Internet.” This question should be added to any evaluation form for new patients, and it is important to ask very specific questions about Internet use and sites commonly visited.

At Timberline, when a patient is first enrolled, often the staff will take the teen’s laptop and put it in secured storage. When the patient is at a place far enough along in recovery where she is willing to delete unhealthy pictures (some even opt to delete their entire Facebook account), either during inpatient treatment or in an outpatient setting, this can be a powerful experience in letting go. Many times these are images that have been hidden in a computer or the teen’s room at home.

During recovery, the Internet can act as a powerful ally to patients who use it to attend online eating disorders recovery sites such as that for Eating Disorders Anonymous, and anorexia-bulimia support recovery sites, such as the National Eating Disorders Association (NEDA) website. Timberline Knolls has a recovery blog site and it has been a helpful tool for patients. Of course, she adds, it is insufficient by itself, and must be part of a comprehensive program that includes face-to-face discussions.

Dr. Dennis tells her teenage and young adult patients that for the next 6 months, they will be asked to surrender their entire image obsession—this is akin to not allowing people with substance abuse to put toxic substances in their bodies, she says. Patients also learn that looking at fashion magazines or the old websites “is part of the early relapse process.”

The average stay for treatment is 45 to 60 days, but this varies widely by patient, and some girls remain at the center for 5 to 6 months. Dr. Dennis and her staff use very careful discharge planning for patients that includes a gentle step-down approach, from residential care to day care to intensive outpatient treatment, then regularly scheduled individual sessions. This may take from 6 to 12 months after leaving the residential program

Once the teen goes back home to live with her parents, the parents will need to monitor sites their teen visits and to use software to block out certain harmful websites, such as the pro-Ana websites. She added that many parents have a difficult time dealing with this but some helpful guidelines are available for parents to use (see “Five Steps Parents Can Take”).

Parental Supervision Was Critical to Success in the Israeli Study

In the Israeli study, the risk of developing eating disorders was moderated with increased parental supervision over the teen’s Internet use. The 248 girls from 12 to 19 years of age first provided information about their Internet and television-viewing habits. As part of this process, they were asked to write down the number of popular shows they regularly watched that were related to extreme standards of physical appearance. They also completed a questionnaire that assessed their approach to losing weight, bulimic behaviors, physical satisfaction or dissatisfaction, general outlook on eating, and their sense of personal empowerment.

Exposure to the media and the consequential sense of personal empowerment were found to be directly associated with parenting practices. When parents were not involved in their daughters’ use of media, didn’t know what the girls were viewing, or reading, or where they were surfing on the web, and didn’t discuss these issues with their girls, the daughters were found to have lower degrees of self-empowerment. The researchers, Professors Yael Latzer, Ruth Katz, and Zohar Spivak, concluded that parents had the potential to prevent dangerous behavioral disorders and unhealthy eating behaviors by paying closer attention to their teens’ Internet use.

Facebook Fires Back

Officials at Facebook have dismissed the findings of Dr. Latzer and colleague’s study with the following statement: “Young people are surrounded by Photoshopped models in magazines and airbrushed film stars, but when they spend time on Facebook they're with their friends." But Dr. Dennis counters these claims. She says, “Teenagers will see in Facebook what they want to see. There are positive and empowering ways to use the site, but there are also more sinister aspects. They might look at a picture of a friend and still see what they think is wrong with themselves. Frequently, girls and women with eating disorders use the site to post ‘skinny’ pictures of themselves when they are deep into their diseases. This can be triggering to other teens and also re-trigger the recovering young women themselves. That’s why parental interest is crucial. But even the most involved and careful parent might miss small details that can become big problems in the future.” —MKS

Five Steps Parents Can Take

Dr. Dennis offers the following advice for parents, keeping in mind that many children and teenagers might revolt against it:

Time Out: Planning the time children have with their computers is crucial. “Parents should limit the amount of time their children are allowed to be online recreationally,” Dr. Dennis advises. “Whether the limit is 30 minutes a day or an hour a day, it is important to give children a set period of time. As time-consuming as this might be for parents, this activity must be monitored carefully.”

Lights Out: Parents must also give their children boundaries on how late they can be online. “The later the hour, the more likely parents will be asleep and unable to monitor the child’s online activities. It also is the time that objectionable pop-up ads are most likely to appear. Worse yet, it is when online predators are scouring the Internet looking for victims,” according to Dr. Dennis.

 

Location, Location, Location: Time is not the only factor; parents need to know where their children are going on the Internet as well. “Look at the site history on your computer,” Dr. Dennis says. She advises parents to “Find out what sites your child frequents and go to those sites to make sure they are appropriate. Prohibit children from visiting sites with objectionable content. If needed, purchase programs designed to block access to certain websites.” Another step to take is to use a shared/family desktop computer and have it in a common area of the house like the kitchen or living room.

Stay in the Loop: Parents should also network with other parents and talk with them about what they are doing and seeing. She suggests, “Talk about children’s’ patterns of computer use, what limits they set, and other ways they cope with use that may be unhealthy or unbalanced. Parents might also want to make sure their kids use a family computer, a desktop located in an open area of the house like the living room or kitchen where other family members are likely to be.”

Keep Informed: Most importantly, parents need to explore what’s going on in their kid’s relationships and lives.