Merrin was a 39 year old woman with a 15 year history of yo-yo dieting with daily self-induced vomiting. She was married with 3 school-age children and living in a rural area 47km outside Aberdeen, where the main hospital and Eating Disorder Service are based. Her eating disorder symptoms included a persistent pre-occupation with eating and an irresistible craving for food, periods of overeating, constant attempts to restrict food intake and vomiting at least once every day. She had lost 7 teeth due to vomiting. There was no evidence of objective bingeing, no use of diet pills, over-exercise, nor laxative abuse. Poor body image was evident, independent of fluctuations in weight, and in particular disgust in relation to her abdomen, back and legs. There was no overt body or weight-checking behaviour. Her weight at treatment onset was 110kg (BMI 39.1) and had ranged between 76kg (4 years previously) and 127kg (5 years previously). Unusually, she did not wish to be thin and considered her ideal weight to be 76kg (BMI 27.5). At this weight she believed she would feel less pressured to lose weight, and would also feel less pressured to maintain a ‘thinner’ BMI within the normal range.

Merrin was independently assessed at pre-treatment by a psychiatric registrar and diagnosed with EDNOS (Eating Disorder not Otherwise Specified) according to the DSM-IV diagnostic system [16]. Her weight was in the obese category. She had a smoking habit and a family history of heart disease and type 2 diabetes, making it a priority to improve her eating habits and reduce weight-related health risks. She had also been diagnosed with a borderline thyroid level. Her mean global score on the Eating Disorder Examination-Questionnaire (EDE-Q) questionnaire [17] at pre-therapy was 4.493, which is significantly higher than the norm (mean: 1.554; SD: 1.21) of a non-clinical population. She also scored higher on all of the subscales, indicating high levels of restrictive eating, associated with marked eating, shape and weight concerns. Pre-therapy ratings on the SCL-90 [18] showed elevated scores on the ‘Somatisation’ (Mean:1.33) and ‘Depression’ (Mean:1.69) subscales, indicating distress arising from bodily perceptions of physical ill-health and low mood, loss of motivation and energy. There was no previous contact with psychiatric services.

All family members except her father were overweight, and as children Merrin and her siblings were expected to finish everything on their plates at each meal. Meals usually consisted of two courses of processed high-calorie foods. Her mother often dieted, but this was not openly discussed. At the age of 12 she first became aware that she was taller and bigger than her peers. She was ridiculed at school for the size of her chest and although she was not teased explicitly about her weight, she assumed that this was the reason that some of her friends withdrew from her at that time. With her mother’s help, she started dieting. Her perception of herself as ‘big and slow’ led to high levels of self-consciousness and an avoidance of school sports activities, social events and parties. She started to self-induce vomiting in order to persuade her mother that she was too unwell to go to school on the days that physical education classes were scheduled. From the ages of 12 to 17 she developed a strong sense of herself as ‘fat’ and unattractive to her peers. She blamed herself for her body size, but was unsure about how to lose weight.

She left school at the age of 16, and worked in a factory, feeling too self-conscious to take on any position that would involve exposure to the public. Her first marriage lasted 7 years. She developed Myalgic encephalomyelitis (ME) after having her first child, leading to exhaustion with joint pain. She described feeling alone and depressed. She was treated with pain-relief and anti-depressant medication. She later remarried and had 2 further children. An apronectomy was performed one year prior to referral to the eating disorder service. Unfortunately this was unsuccessful due to subsequent weight gain and resulted in a suspected hernia which interfered with her attendance at some of her scheduled video therapy appointments.

Merrin developed a complex relationship with food from a young age. The majority of family members were overweight and she developed a sense of feeling different from her peers and stigmatized due to her shape and weight. Her avoidance of physical exercise further reduced opportunities for energy expenditure. Her first attempt at dieting at the age of 12 was unsustainable due to the fact that her family was entrenched in eating large high energy meals. She began to develop strong schemas (extremely stable and enduring patterns that develop during childhood and are elaborated throughout an individual’s life) defining her self-worth and lovability. One of her strongest schemas was Social Undesirability (‘I’m fat’, I’m not sexually attractive’,’ I’m ugly’) which was linked to self-consciousness around other people. She believed that she was not good enough and that others would ultimately abandon her. She learned to reduce the (perceived) likelihood of rejection and abandonment through sacrificing herself to meet others’ needs and demands. Merrin learned to use eating as a way of comforting herself and detaching from difficult emotions, especially when feeling rejected or unloved. High levels of internalized shame led her to despise and blame her body. Restriction and vomiting were used to punish herself for eating what others would consider normal meals. She consistently skipped meals, and when distressed would often restrict for a day or more at a time. This led to periods of overeating, followed by further vomiting episodes, thus developing a vicious cycle. Hypervigilant internal body scanning took place after even small amounts of food and she was sensitised to any sensations of fullness or bloated-ness. This was linked to immediate urges to relieve discomfort through vomiting. Signs of fullness were experienced as uncomfortable and interpreted as a sign of potential weight gain. The onset of ME exacerbated her perception that her body was out of her control and further reduced opportunities for physical exercise and weight loss.

The present study relied on an AB design, representing assessment (A) and treatment (B). As is usual practice in the service, standardised measures were administered at intake (Eating Disorder Examination Questionnaire (EDE-Q); CORE [19], pre-therapy (EDE-Q, CORE, SCL-90, Rosenberg Self-Esteem Scale [20], Schema Mode Inventory [21], mid-therapy (EDE-Q, CORE, Working Alliance Inventory (WAI) [22]) post-therapy (EDE-Q, CORE, SCL-90, Rosenberg Self-Esteem Scale, WAI) and one-month follow-up (EDE-Q, Rosenberg Self-Esteem Scale, CORE). The Client Change Interview Protocol [23] was also carried out by telephone at mid- and post-therapy by a doctoral level Clinical Psychology Trainee (LS). A daily diary was also kept to record food eaten and eating disorder symptoms.

Merrin was referred by her General Practitioner (GP) and was triaged before being placed on the Grampian Eating Disorder Service waiting list. From the point of referral she waited for 18 weeks for treatment. Before her first treatment session, Merrin was contacted by telephone and offered video therapy. Transport difficulties and logistics of childcare made attendance at regular face-to-face appointments in Aberdeen impractical. A ‘Video-therapy: What to expect’ information sheet was sent with the first appointment letter. Treatment took place at her local community hospital on the videoconferencing system in the Minor Injuries Unit, a 10 minute drive from her home. A clinical psychologist trained at doctoral level (SS) conducted sessions from a Tandberg videoconferencing system (56cm width screen) based at the Eating Disorder Service at Royal Cornhill Hospital, Aberdeen. The screen was pre-set at both ends so that the view was of torso and head. However, this view could be changed at any time by therapist or client by remote control. All sessions were conducted at ISDN 6 through the internal National Health Service network. Merrin was advised to attend her GP and dentist for regular physical check-ups throughout treatment.

The schema ‘mode’ therapeutic model [24] was chosen to address the longstanding nature of her eating difficulties and chronic low self-esteem dating back to childhood. Initial data suggest that this model may be highly relevant to the eating disorder population and that schemas may be linked with specific eating disordered behaviours [1, 25]. In the first two weeks of therapy Merrin learned to self-monitor her eating patterns and to link these with emotional triggers. Regular meals and snacks were slowly re-introduced and catastrophic cognitions in relation to weight gain were challenged. Behavioural strategies were used to plan meals and delay and eventually replace vomiting. Mode dialogues (an experiential chair-work technique) were used to challenge her extreme patterns of self-criticism, self-shaming and longstanding avoidant coping strategies. Imagery techniques were used to re-script early memories of being blamed and teased and to heal the underlying emotional damage caused by these experiences. She gradually learned to value herself and to relate to herself from a healthier compassionate position. Her eating patterns normalised as she began to conceptualise food as a necessary requirement, rather than as something ‘sinful’ which she should be able to resist. She learned to ask for comfort, practiced healthier patterns of self-soothing when distressed, and began to blame herself less in the face of conflict and others’ negative behaviour. Sessions focused on increasing awareness of her needs and learning to be assertive. Schema ‘flashcards’ were used to challenge self-criticism, alert her to use her new coping strategies and affirm her inherent self-worth. Body image work took place through imagery and behavioural exercises and focused on developing a holistic view of herself by considering all the different aspects of her ‘self’ rather than defining herself entirely on the basis of one or two body parts. She began to examine herself from the (accurate) perspective of others, rather than through her ‘Social Undesirability’ schema. This work was facilitated by the videoconferencing – she was able to view herself using the Picture-in-Picture facility and to challenge any self-deprecatory statements that were triggered. The document camera linked to the videoconferencing unit was used to project her formulation diagram and homework onto the screen to facilitate communication. Email was utilized to reinforce material covered in sessions, to send out monitoring diaries, to send homework exercises and to give feedback on food diaries.

Global EDE-Q scores stayed stable between initial referral and pre-therapy (18 weeks), but then decreased from 4.49 at pre-therapy to 1.8 at post-therapy, placing her within the range of the normal population. This was a decrease of 77 % in severity of eating pathology. There was improvement on all subscales, as shown in Table 1. This improvement in eating disordered symptoms was verified by self-report diaries. At pre-treatment vomiting was taking place on average six to eight times per week. Daily eating diaries indicated that in weeks 1 to 3 she vomited three times per week and missed at least 3 meals per week. In the final 28 days (i.e. weeks 7,8,9,10) of treatment she was abstinent from vomiting. Her weight had dropped to 103kg (BMI 36.7). At one-month follow-up her EDE-Q global score had further decreased to 0.46.

On the CORE there was marked improvement on all subscales, with an 86% reduction in global distress between pre and post-treatment (1.29 - 0.18). By one-month follow-up her global distress score was 0.29, well below the clinical cut-off score and within the ‘normal’ range. Scores on the Rosenberg Self Esteem Scale showed an improvement between pre-therapy (20 = low) and post-therapy (26 = above ‘normal range’). At one-month follow-up her score of 22 was within the ‘normal range’. At post therapy, mean scores for all 12 maladaptive schema modes were within one standard deviation of the normal population (compared with 6 at pre-therapy). The SCL-90 Global Severity Index mean score decreased by 72% between pre- and post- treatment (0.99 - 0.28), with a 73% reduction (1.69 - 0.46) on the depression subscale.

The therapeutic relationship, as measured by the WAI was rated at the maximum level (total score of 84) both at mid and post therapy, suggesting that the use of videoconferencing as a mode of treatment delivery did not interfere with the development of a positive therapeutic rapport. This was further supported by ratings on the self-developed Video Therapy questionnaire, which showed maximum satisfaction on quality of sound, picture and ‘ease of communication’. Results from interview indicated that rapport was in some ways enhanced by video therapy see Table 2.