Using Video to Reach Remote Patients

One-third of the population of Scotland has no access to specialized eating disorders services. Those who live in rural or remote areas are at a particular disadvantage. For many, the prospect of traveling to and from city centers to have weekly therapy sessions is impractical due to distance, expensive and often unreliable transport choices, and severe weather, to name but a few of the obstacles.

In 2003, the Grampian Eating Disorder Service, based in northeast Scotland, developed a video-therapy service that offers specialist psychological and nutritional therapy for eating disorders. In one study, 12 patients treated with the video therapy service consistently reported having a high level of satisfaction with all aspects of video therapy, and after their last session 67% preferred video-therapy to face-to-face therapy, largely because of the convenience. Nutritional knowledge increased for all patients, and the quality of the nutrients in her diet also markedly improved over the course of therapy (J Telemed Telecare. 2003; S1:S37-8.)

Drs. Susan G. Simpson and Lindsey Slowey recently reported the results of a pilot study using videoconferencing within the Grampian system to treat a 39-year-old woman with a 15-year history of yo-yo dieting with self-induced vomiting. The patient, who had a body mass index of 39.1, reported constant preoccupation with eating and an irresistible craving for food, periods of overeating, constant attempts to restrict food intake and vomiting at least daily. The woman was married and had 3 children.

The woman was referred by her general practitioner and was placed on the Grampian Eating Disorder Service waiting list; she waited 18 weeks for treatment. Transportation difficulties and problems arranging child care made it impossible for her to attend face-to-face appointments. Thus, she agreed to treatment with videoconferencing using her local community hospital, a 10-minute drive from her home.

The schema mode therapeutic model was selected to address the longstanding nature of her eating difficulties and chronic low self-esteem, both of which dated back to her childhood. During the first two weeks of therapy she learned to self-monitor her eating patterns and to link these with emotional triggers, Regular meals and snacks were slowly reintroduced and her catastrophic cognitions in relation to weight gain were challenged. In addition, the therapist offered behavioral therapies to delay and eventually replace vomiting. Mode dialogues (an experimental chairwork technique) were used to challenge her extreme self-criticism, self-shaming, and longstanding avoidant coping strategies.

Over 11 weeks, the woman had seven video therapy appointments and one telephone appointment. The appointments were scheduled twice weekly for the first 4 weeks and then weekly afterward. Four appointments were cancelled due to heavy snow, transport difficulties, and a medical issue (suspected hernia) and were substituted with telephone appointments and follow-up email exchanges.

The authors reported that following 11 weeks of video therapy, the woman’s Global Eating Disorder Examination Questionnaire scores decreased from 4.49 before therapy to 1.8 after therapy. At baseline, the woman was vomiting an average of 6 to 8 times a week; by weeks 7-10, she became abstinent from vomiting. Her weight dropped to a BMI of 36.7. The researchers also recorded an 86% reduction in global distress between pre- and post-treatment (CORE) and by one month follow-up, her global distress score was 0.29, well below the clinical cut-off level and within the “normal” range. Scores on the Rosenberg Self-Esteem Scale showed an improvement and at one month follow-up her score was 22 was within the normal range.

The use of videoconferencing did not interfere with developing a positive therapeutic rapport, which was supported by rating on the self-developed Video Therapy questionnaire which showed maximum satisfaction with the quality of sound, the video picture, and the ease of communication.

According to the authors, this pilot study suggests that video therapy may be an acceptable and effective method for treating patients with co-morbid obesity and eating disorders.