September/October 2009 Issue

Eating Disorders on the Web — The Pro-Ana/Pro-Mia Movement
By Jennifer Van Pelt, MA
Social Work Today
Vol. 9 No. 5 P. 20

Google the word “anorexia” and the fifth search result is a link to a pro-anorexia (pro-ana) Web forum, which is mixed with links to well-respected medical Web sites. Google the words “thin and beautiful” and the top two search results are pro-ana Web sites, as well as the suggested search phrase “how to become anorexic.” Similar results may be found for pro-bulimia (pro-mia) Web sites.

Once a secret illness, anorexia has reached the limelight on the Internet among adolescent girls hoping to eventually look like their favorite excessively thin celebrity idol. Despite efforts to raise awareness of the dangers of extreme weight loss and eating disorders, the pro-ana and pro-mia movements have proliferated in cyberspace, and the number of young girls and women with eating disorders has increased.

According to the National Institute of Mental Health, the National Eating Disorders Association, and the Alliance for Eating Disorders Awareness, one in five women has an eating disorder or disordered eating, and 90% of these women are aged 12 to 25. Anorexia is the third most common chronic illness among adolescents. These statistics are suspected to be underestimated due to the secrecy and shame associated with eating disorders, preventing many cases from being reported.

Eye-Opening Internet
Amy N. Spahr, MSW, LCSW, corporate director of clinical services for Remuda Ranch programs, has specialized in eating disorders treatment for the past 15 years. Given that the Internet is a primary means of communication and social connection for adolescents aged 13 to 19, two thirds of adolescent girls seek health information online, and nearly one half of this group is looking for ways to lose weight and one fourth for eating disorder information, says Spahr, it is no surprise that pro-ana and pro-mia Web sites have become more prevalent and are a substantial influence on adolescents with eating disorders.

Hundreds of pro-ana and pro-mia Web sites are active and hundreds, if not thousands more, link to blogs, forums, and pro-ana Internet images that are easily located by the young cyber generation. “Some Web sites will promote eating disorders as a lifestyle choice rather than an illness; share extreme weight loss tips; give advice for hiding behaviors from friends, family, and doctors; post body weights and measurements with details of dietary plans; and post ‘thinspiration’ pictures of emaciated young girls and women to encourage further weight loss,” Spahr notes.

“The Internet has had a huge effect on the accessibility of ‘how-to’ information for persons with anorexia and/or bulimia,” says Adrienne Ressler, MA, LMSW, CEDS, national training director for The Renfrew Center Foundation and president of the International Association of Eating Disorder Professionals. “With the advent of social networking sites like MySpace and Facebook, the pro-ana movement now reaches a much wider audience,” Ressler adds, noting that impressionable young girls can become “friends” or be “friended” by pro-ana groups on popular social networking sites. The “tips and tricks” that previously were only available by word of mouth from a small circle of people in the days before the Internet are now just a point and click away or, even worse, sent automatically via e-mail.

Unfortunately, some of these Web sites initially appear to be supporting recovery from an eating disorder but are actually disguising pro-ana/pro-mia messages within the context of “healthy” eating advice. So even those intending to look for recovery help from an eating disorder may be sucked back into the pro-ana/pro-mia mindset. “Pro-ana Web sites are horrifying and so distorted, so opposite of healthy,” says Karen R. Koenig, LCSW, MEd, a psychotherapist, an educator, and a writer specializing in compulsive, emotional, and restrictive eating. She believes that the Internet is a primary reason why so many young girls and women now view excessive thinness positively and that accessibility to pro-ana images on the Internet has been very harmful.

“Pro-ana groups work very much like a cult religion,” says Koenig, luring in girls in their teens and early 20s with misperceptions about their weight and body image that make them vulnerable to pro-ana/pro-mia messages. Individuals with eating disorders have an underlying need for reinforcement of their beliefs, which they find on these Web sites, Koenig says.

The ease of accessing pro-ana information on the Internet may push them over the edge. Ressler adds, “Many young girls are poised to become anorexic.” She cites the example of a 14-year-old gymnast with a fashion interest—already in a sport where weight and eating habits can be an unhealthy emphasis—who visits fashion Web sites and sees photos of emaciated celebrities portrayed as beautiful. Internet searches for these celebrities will undoubtedly provide links to pro-ana Web sites, Ressler explains.

She compares the cultural evolution of pro-ana Web sites to that of pornography, which, while still meeting with disapproval from the American public, seems to have become almost accepted as commonplace on the Internet. “What initially was viewed as very shocking has now become familiar and neutralized,” she says. In this vein, pro-ana sites compete to outdo each other with body images and advice, to draw in new “recruits.” “They are like a contagion,” Ressler says. A high percentage of Renfrew clients are frequent users of, or at least very familiar with, pro-ana Web sites, she notes.

Research
The tremendously negative influence of these Web sites has been documented in some studies, according to Spahr. In one study of almost 700 families with an adolescent with an eating disorder, the use of pro-ana and pro-mia Web sites correlated with longer disease duration and more hospitalizations, and 96% of teens diagnosed with an eating disorder who visited these sites learned new dieting and purging techniques. About 50% of teens who visited sites ostensibly devoted to eating disorder recovery also learned new weight loss tips (Wilson, Peebles, Hardy, & Litt, 2006).

Another study of more than 1,500 participants found that viewers of pro-ana/pro-mia Web sites had higher levels of eating and body image disturbances than the control group (Harper, Sperry, & Thompson, 2008). And yet another study that compared the viewing of a pro-ana Web site with female fashion Web sites with average-sized models found that those exposed to the pro-ana sites had a greater negative affect, lower social self-esteem, and lower appearance self-efficacy after viewing the Web site than those who viewed the other sites. Pro-ana Web sites also influenced viewers to exercise more and think about their weight and to compare themselves with Web site images of women (Bardone-Cone & Cass, 2007).

Combating the Anorexic Addiction
Anorexia is not just about extreme dieting; it involves a proclivity for a certain way of thinking and behaving, and pro-ana Web sites feed that tendency. “The communities formed via pro-ana Web sites provide dysfunctional support for those thoughts and behaviors,” Ressler explains. Ongoing research in the field of psychoneurology suggests that disorders of attachment and affect contribute to pro-ana community-forming behaviors, feeding the need to form relationships (albeit dysfunctional) that support eating disordered behaviors (Ressler, 2008).

Treatment and activities that focus on the mind and the body are often utilized to redirect thought processes about body image. Ranging from more traditional cognitive behavioral therapy (CBT) or psychotherapy to methods once considered alternative, such as yoga, dance/movement and art therapy, and meditation, treatments that have an integrative mind/body component are often successful. Ressler says such treatments can be used by social workers to help redirect clients to individuals and resources that create positive attachments, thereby countering the effect of pro-ana Web sites. “The authentic therapeutic alliance between the social worker and the client can repair deficits in attachment [common in anorexia] and help break those dangerous attachments to communications with individuals active on pro-ana Web sites,” she explains.

Replacing Unhealthy Attachments
“These individuals identify with pro-ana Web sites because they represent and support the more destructive messages of the self,” Ressler says. Replacing attachments to pro-ana Web sites, thoughts, and behaviors is critical to getting well, as is dealing with the identity issues that are a struggle for many individuals with eating disorders. “Creating positive rituals that honor the self, celebrating life, and establishing normal eating are necessary,” says Ressler.

Renfrew recently started involving alumni who have a strong recovery history with others who may still be struggling. Through Webinars and regional support groups, Renfrew clinicians and selected alumni form a support system that works in tandem with other therapies and activities.

Frequent visits to pro-ana Web sites must be replaced by a more positive behavior, and for many adolescents so reliant on the Internet, pro-ana Web sites can be replaced with other Internet resources. While the Internet does make pro-ana and pro-mia information easily accessible to impressionable individuals, it also provides a venue to reach out to those in need of help. “The Internet makes it easier to find healthy information, too. And it provides a means to connect those who would not otherwise join a therapy or support group in person,” Koenig says. Message boards, support forums, online counseling and motivational messages, and healthy eating Web sites can all be used to replace the pro-ana and pro-mia Web sites and online communication for individuals who primarily seek information via the Internet. 

However, therapists must avoid directly forbidding pro-ana Web site access, instead providing guidance to help the client make the move to healthier alternatives. Koenig cites the example of a ballet dancer with anorexia who gravitated toward pro-ana Web sites. Using CBT to explore her beliefs and needs, Koenig helped direct her toward more positive Web sites to support healthy eating habits. “CBT can be a very powerful tool for therapists,” Koenig says. Lecturing someone with an eating disorder may just drive them deeper into their behavior patterns. Applying CBT can help them uncover their own conflicted feelings about pro-ana behaviors and sites, leading them to discover on their own how unhealthy and damaging the Web sites are. “Then you have created the opportunity for them to explore alternative Web sites and peer groups that support healthy eating behaviors,” she adds.

Remuda Ranch therapy programs explore the media’s influence on clients’ current body image constructs. “The representation of ‘thinspiration’ images is virtually impossible and unhealthy for most women and men to achieve, and many of the images used are actually computer-enhanced images and are unrealistic of a normal body size and shape. When young girls and boys are repeatedly exposed to these images, the result can be discontent and dissatisfaction with their bodies,” Spahr notes.

Social workers should also beware that they do not inadvertently introduce clients with eating disorders to pro-ana/pro-mia Web sites. Use of these Web sites is more common for adolescent girls. Spahr estimates that only about 13% of college-age students look at pro-ana/pro-mia Web sites; it is mostly an adolescent trend. She advises that professionals use indirect questions to assess their clients’ usage of pro-ana and similar Web sites. “Clients may not have been exposed to these forums and once they become aware of them, they will most likely begin to explore this resource,” she says. An alternative assessment may include asking, “How much time do you spend online?”, “What kinds of things do you do online?”, and “How has the media influenced you?” Assessing online behavior in this way can help determine the frequency and amount of Internet usage without introducing a new negative resource for clients.

Treatment Models
After assessing the client’s Internet usage and potential addiction to pro-ana/pro-mia Web sites and online communities, Spahr says the next clinical step is to address the issues underlining attachment to these Web sites, which may include identity, self-expression, and communication. “Clients will often use these Web site forums for acceptance and validation. They will need to learn alternative skills to manage these needs and restore their identity in a healthy way,” she advises. Remuda’s treatment model is a biopsychosocialspiritual model, which allows treatment of the whole person using therapeutic interventions such as CBT.

Eating disorder behaviors, such as those that incorporate unhealthy usage of the “thinspiration” Web sites, often become a tool individuals use to meet needs, and an essential component in treating them relies on understanding the function(s) in order to effect therapeutic change, Spahr explains. “CBT helps our patients distinguish beliefs, perceptions, cognitions, and behaviors that are rational and appropriate from those that are irrational and inappropriate. CBT is especially helpful in teaching patients adaptive and effective skills to help them manage their emotions. During the course of therapy, changing behaviors and applying CBT skills will increase the patient’s understanding of the functions of his or her eating disorder and in the process identify antecedents that lead to problem behaviors,” she says. If spending time on pro-ana/pro-mia Web sites created an increase in maladaptive behaviors, the therapist can help the client explore prevention strategies that will decrease such behaviors in the future.

Remuda therapists also use the biopsychosocialspiritual model to guide body image therapy. Psychoeducational and experiential therapies are used to explore the underlying body image issues of each patient and challenge the maladaptive thoughts, feelings, and behaviors. At Renfrew, similar strategies are used, and Ressler says more newly incorporated therapy activities that involve spirituality and the expressive therapies have also been particularly successful. “Renfrew clients have responded very well to therapies that speak to spirituality,” she says. For example, a healing garden at the Florida center provides a popular setting for exploring spiritual issues, meditation, and group therapy sessions in which patients learn to replace negative rituals with positive ones. Expression through art, music, dance, and gentle yoga are effective in helping clients release stored emotion in a way that words sometimes cannot, says Ressler.

“Engaging with positive people performing positive interventions is key,” she says, adding a word of caution that dance and yoga instructors and classes must be carefully screened as resources to make sure that certain negative behaviors, such as an emphasis on thinness and strenuous calorie-burning exercise, are not reinforced. “Power yoga, for instance, would not be a good type of activity for the recovering anorexic,” she explains.

Social workers treating clients with eating disorders should take time to visit pro-ana/pro-mia Web sites to know exactly what they must battle in therapy sessions. Many social workers outside specialized eating disorder treatment centers remain unaware of the extent to which pro-ana/pro-mia groups have infiltrated popular social networking Web sites that most adolescents frequent daily. “Knowing the enemy” can better inform therapeutic strategies for clients with eating disorders and hopefully support social workers in providing successful, positive alternatives. The pro-ana and pro-mia movements are insidious, thriving in today’s cyber culture, Ressler believes. “This culture does not make it easy to recover from anorexia and other eating disorders,” she says.

— Jennifer Van Pelt, MA, is a Reading, PA-based freelance writer with 15 years of experience as a writer and research analyst in the healthcare field. She has written on depression, attention-deficit/hyperactivity disorder, schizophrenia, mental wellness, and aging.

Pro-Ana and Pro-Mia Web Site Excerpts

www.prettythin.com/beautiful.htm
Let’s face it... Being Ana takes it’s toll on our bodies, inside and out. So here are some helpful tips on keeping up lookin’ good on the outside.

• At a certain weight, which is different for everyone, you will lose your period. This is a good thing because it means that you’re losing weight. Still, it would be wise if you’d take calcium supplements, if you don’t already. Don’t let your mother find out about your lost period because she will most likely take you to the doctor. Never under any circumstances tell a doctor that you’ve lost your period. They will have you in an eating disorder clinic faster than you can say “What the hell?” Before you go to the doctor’s, make sure that you have a date to tell them in case they ask about your last period, and make sure the date is believable.

www.skinny.rocks.it
Tips and Tricks

• Eat Ice cubes, they give you the feel like your eating something and the coldness can actually burn calories.

• Go to the kitchen often, and pretend your snacking, take a bite out of something and take a long time, look in the fridge stuff like that. People will always think your eating!

References
Bardone-Cone, A. M., & Cass, K. M. (2007). What does viewing a pro-anorexia website do? An experimental examination of website exposure and moderating effects. International Journal of Eating Disorders, 40, 537-548.

Harper, K., Sperry, S., & Thompson, J. K. (2008). Viewership of pro-eating disorder websites: association with body image and eating disturbances. International Journal of Eating Disorders, 41(1), 92-95.

Ressler, A. (2008). BodyMind Treatment: Connecting to Imprinted Emotions and Experiences. In M. D. Maine, W. N. Davis, J. Shure (Eds), Effective clinical practice in the treatment of eating disorders: The heart of the matter. (pp. 145-162) New York: Taylor & Francis Group.

Wilson, J. L., Peebles, R., Hardy, K. K., & Litt, I. F. (2006). Surfing for thinness: A pilot study of pro-eating disorder web site usage in adolescents with eating disorders. Pediatrics, 118, e1635-e1643.