ArticlePDF Available

"It's the Symptom of the Problem, not the Problem Itself." A Qualitative Exploration of the Role of Pro-Anorexia Websites in User’s Disordered Eating

Taylor & Francis
Issues in Mental Health Nursing
Authors:

Abstract and Figures

The growing trend in the use of the Internet and social media as a method of self-managing illness presents a critical opportunity to better understand the role of pro-anorexia websites for eating disorders. Therefore, one hundred and fifty five pro-anorexia website messages regarding criticism that the site was responsible for developing anorexia were inductively thematically analysed. The analysis revealed five main themes: eating disorders are mental illnesses and websites do not cause mental illness, pro-anorexia websites and eating disorders are more than wanting to be thin (with sub-theme residents and visitors), eating disorders develop regardless of pro-anorexia websites, pro-anorexia sites don’t cause eating disorders but they may trigger or encourage them (with sub-theme the problem is the user, not the site) and pro-anorexia sites provide support. Pro-anorexia websites and online communities present clinicians with complex treatment challenges. Collaborative, therapeutic consultations about pro-anorexia website use may help to establish how and when accessing them may hinder the treatment process.
Content may be subject to copyright.
Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=imhn20
Issues in Mental Health Nursing
ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: https://www.tandfonline.com/loi/imhn20
“It’s the Symptom of the Problem, Not the Problem
itself”: A Qualitative Exploration of the Role of Pro-
anorexia Websites in Users’ Disordered Eating
Charlotte Emma Hilton
To cite this article: Charlotte Emma Hilton (2018) “It’s the Symptom of the Problem, Not the
Problem itself”: A Qualitative Exploration of the Role of Pro-anorexia Websites in Users’ Disordered
Eating, Issues in Mental Health Nursing, 39:10, 865-875, DOI: 10.1080/01612840.2018.1493625
To link to this article: https://doi.org/10.1080/01612840.2018.1493625
Published online: 11 Oct 2018.
Submit your article to this journal
Article views: 183
View Crossmark data
Its the Symptom of the Problem, Not the Problem itself: A Qualitative
Exploration of the Role of Pro-anorexia Websites in UsersDisordered Eating
Charlotte Emma Hilton
Department of Health and Life Sciences, School of Psychological, Social and Behavioural Sciences, Coventry University, Coventry, UK
ABSTRACT
The growing trend in the use of the Internet and social media as a method of self-managing ill-
ness presents a critical opportunity to better understand the role of pro-anorexia (pro-ana) web-
sites for eating disorders. Therefore, 155 pro-ana website messages regarding criticism that the
site was responsible for developing anorexia were inductively thematically analysed. The analysis
revealed five main themes: eating disorders are mental illnesses and websites do not cause mental
illness, pro-ana websites and eating disorders are more than wanting to be thin (with sub-theme
residents and visitors), eating disorders develop regardless of pro-ana websites, pro-ana sites do
not cause eating disorders but they may trigger or encourage them (with sub-theme the problem
is the user, not the site) and pro-ana sites provide support. Pro-ana websites and online commun-
ities present clinicians with complex treatment challenges. Collaborative, therapeutic consultations
about pro-ana website use may help to establish how and when accessing them may hinder the
treatment process.
Introduction
There is a high prevalence of eating disorders such as ano-
rexia nervosa and bulimia in most developed countries
(Hoek & van Hoeken, 2003; Smink, van Hoeken & Hoek,
2012). In the UK, clinical guidance to manage eating disor-
ders in individuals as young as 8 years old has been pub-
lished by the National Institute for Health and Care
Excellence (NICE, 2004) and replaced more recently with
guidance regarding the recognition and treatment of eating
disorders (NICE, 2017). The Internet has created inter-
active opportunities for those seeking help and support to
pursue thinness and the emergence of pro-anorexia(or
pro-ana) websites contribute specifically to this aim. Such
websites have been deemed as supporting a positive atti-
tude towards disordered eating and consider any associated
illness as a lifestyle choice rather than something that
should be pathologizedit is perhaps for this reason that
the use of pro-ana websites is considered so controversial
(Bates, 2015).
Access to the Internet and social media has transformed
the way in which people talk about wellness, illness and seek
out sources of support from like-minded others. For
example, recent research has identified the use of social
media sites for pro-ana groups (e.g., Bates, 2015) and those
who self-harm (Hilton, 2016). It is likely that the utility of
such sites for self-managing a range of clinical issues will
continue to grow because social media provides opportuni-
ties for users to explore their experiences with others in an
easy to access and anonymous way. Therefore, the Internet
and social media as a method of self-management presents
itself both as an opportunity to source much needed support
from others but also runs the risk of normalising mental
health difficulties and potentially delaying treatment
(Hilton, 2016).
The influence of the interactional creation of community
that pro-ana websites provide is considered so important
that this has been deemed to supersede whether or not users
meet the clinical criteria for a diagnosis of anorexia (Boero
& Pascoe, 2012). However, pro-ana sites continue to gener-
ate concern and evidence of their potential negative impact
upon the users health and well-being is being documented
in the scientific literature. For example, in an experimental
study, Bardone-Cone and Cass (2007) observed that individ-
uals exposed to a pro-ana website had greater negative
affect, lower social self-esteem and lower appearance self-
efficacy than those who viewed a comparison website. Even
fairly short (1.5 hour) exposure to a pro-ana website by
female college students of healthy weight resulted in reduced
caloric intake that persisted for 3 weeks post-study end (Jett,
LaPorte & Wanchisn, 2010). Concerns that individuals visit
pro-ana sites to initiate or maintain disordered eating have
also been substantiated (Csipke & Horne, 2007). Although
conversely, the capacity for pro-ana sites to provide a source
of support and online community has also been acknowl-
edged (Brotsky & Giles, 2007; Mulveen & Hepworth, 2006).
It is perhaps because of this dichotomy between the role of
pro-ana sites as potentially initiating and maintaining
CONTACT Charlotte Hilton charlotte.hilton@coventry.ac.uk Department of Health and Life Sciences, School of Psychological, Social and Behavioural
Sciences, Coventry University, Richard Crossman Building, Coventry CV1 5FB, UK.
!2018 Taylor & Francis Group, LLC
ISSUES IN MENTAL HEALTH NURSING
2018, VOL. 39, NO. 10, 865875
https://doi.org/10.1080/01612840.2018.1493625
disordered eating, yet also providing much needed support
to those who feel poorly understood that these sites are of
increasing interest to both the academic and practitioner
communities.
With approximately a third of patients with eating disor-
ders reporting to have used pro-ana websites
(Christodoulou, 2012) and Internet Google searches for pro-
disordered eating content being performed more than 13
million times a year (Levine, 2012), it is critical that the role
and impact of accessing these sites upon the aetiology,
course and treatment of eating disorders is better under-
stood (Norris, Boydell, Pinhas, & Katzman, 2006). Indeed, it
has been recently deemed as an urgent issue (Custers, 2015).
Therefore, this article reports a qualitative exploration of the
role and impact of pro-ana websites upon eating disorders
from the perspective of those who access them. Whilst the
content of pro-ana sites has been explored in the literature
more generally (e.g., Mulveen & Hepworth, 2006; Norris
et al., 2006), the current study is the first of its kind to
assess such views using data that were generated from a
website post that directly blamed the site for her friends
eating disorder. Therefore, it is the first study to utilise data
that are capable of specifically addressing what role and
impact users feel pro-ana websites have regarding their own
and others eating behaviours. This is something that has
consistently been questioned both within the scientific litera-
ture (e.g., Harper, Sperry & Thompson, 2008; Lyons, Mehl,
& Pennebaker, 2006) and also has implications for practice
(Harshbarger, Ahlers-Schmidt, Mayans, Mayans, &
Hawkins, 2009).
Methods
Design
The current study utilised naturally occurring data generated
from a pro-ana website and employed a qualitative inductive
thematic approach to analysis. For a more detailed account
of the approach, the interested reader is signposted to
Braun, Clarke, and Terry (2014) and Braun and Clarke
(2006,2013). However, further detail is provided within the
data handling sub-section.
Participants
The participants for the study comprised 151 members of a
pro-ana website. Participants were obtained through an
opportunity sample of postings made on a discussion forum.
As the participants were not purposefully recruited, demo-
graphic information such as age and gender were not avail-
able. It is assumed from the nature of the data that most, if
not all, of the participants perceive themselves to have an
eating disorder. However, it is unknown if the participants
had received a formal diagnosis. To maintain anonymity,
participants are referred to numerically, by the order of the
response that they made to the online message and these
responses range from 1 to 155.
Materials
The data set was collated in June 2016 and comprised 155
messages. The specific context of the messages included in
the analysis was that they were responses to a message sent
to the site moderator blaming the website for their friend
developing anorexia. Utilising the context of the messages
for data analysis in this way provided a unique opportunity
to specifically assess usersviews regarding the perceived
role and function of the website. This was achieved through
the inductive thematic analysis of the written responses to
this online message (see Braun & Clarke, 2006,2013; Braun
et al., 2014).
Procedure
Ethical approval to conduct the current study was granted
by a UK university. Permission to use the website for
research purposes was granted from the Website
Administrator and The British Psychological Society (BPS,
2013) Ethics Guidelines for Internet-Mediated research were
adhered to throughout the research process. There was no
communication between the researcher and the participants.
Data handling
Ethical considerations regarding confidentiality and ano-
nymity were taken into account throughout the research
and data handling process. For example, the name of the
website itself, the name of the site administrator, and all
pseudonyms and signatures were removed or replaced with
symbols. The process of data analysis was iterative whereby
the researcher reviewed the entire data corpus and coded
sections, offering interpretations and developing common
themes as they were identified. Theme titles were modified
as this process progressed and intimacy with the data devel-
oped. The analysis employed five of Braun and Clarkes
(2006) six-phase guide to thematic analysis.
The transcription of verbal to written data phase was not
required because the data source was written. To begin,
familiarisation with the data was gained by reading through
the data corpus several times and making notes of com-
monly occurring discussion points. Phase two utilised com-
puter-assisted qualitative data analysis software QSR NVivo
(v.10) to aid the coding process. The complete data corpus
was coded, often with multiple titles and phrases such that
potential themes or patterns could be identified as the ana-
lysis progressed. Phase three of the analysis involved review-
ing the coded data and identifying broad patterns (themes)
within them. The note-taking (memo) function of NVivo
allowed the researcher to draw attention to relationships
between codes and start to identify main themes and the
potential sub-themes within them. These initial themes were
subject to a process of refinement during the fourth phase
of analysis whereby the coded data were scrutinised accord-
ing to if it was a good fitto the theme to which the codes
had been allocated. The final phase of analysis sought to
refine the thematic titles allocated to the coded data.
866 C. E. HILTON
Throughout the process of the analysis, the theme titles
became more specific and better reflected the content of the
coded data. For example, data coded into the theme with
the final title: eating disorders are mental illnesses and web-
sites do not cause mental illness was coded as mental ill
healthearly in the analytical process.
As an additional quality measure but a process not
included within Braun and Clarkes(2006) analysis recom-
mendations, the final groupings of themes and sub-themes
were reviewed by an independent researcher experienced in
qualitative analysis and agreed through a process of peer
debriefing (e.g., Spall & Stephen, 1998). Specifically, the the-
matic titles and coded data allocated to these themes were
critically reviewed and assessed for accuracy in a manner
that replicated the fourth and fifth phases of analysis
described previously. This final phase of analysis resulted in
few but meaningful changes to some of the language used to
describe the themes. For example, the sub-theme residents
and visitorswas previously described as regular and infre-
quent users. However, the revised terms residentsand
visitorsreflected the views of individuals more accurately
because the pro-ana site was referred to as homeby a
number of site-users.
Results
An inductive approach to thematic analysis revealed five
main (higher order) themes: eating disorders are mental ill-
nesses and websites do not cause mental illness, pro-ana
websites and eating disorders are more than wanting to be
thin (with sub-theme residents and visitors), eating disorders
develop regardless of pro-ana websites, pro-ana sites do not
cause eating disorders but they may trigger or encourage
them (with sub-theme the problem is the user, not the site)
and pro-ana sites provide support. What follows is a detailed
account of the findings. In each case, verbatim quotes from
the data have been used to exemplify each of the themes and
these quotes are presented using the order number that the
commentary appeared within the data corpus (i.e., 1155).
Lower numbers reflect posts that were made earlier on in the
discussion, whereas larger numbers reflect views that were
introduced later on. To preserve the true nature of the data,
no alterations to the text have been made which includes
spelling and grammar although the name of the website that
generated the data has been protected by replacing any refer-
ences made to it with !!!. Throughout the text, the abbrevi-
ation ED used by respondents refers to eating disorders. Any
additional abbreviations or text that requires clarification is
provided [within square brackets]. For ease of understanding,
Table 1 presents a summary of the findings followed by a
detailed report of each of the themes and sub-themes with
the use of verbatim quotes to exemplify them. Figure 1 also
presents a conceptual model of how pro-ana website use
may contribute to eating disorders.
Eating disorders are mental illnesses and websites do
not cause mental illness
Throughout the discussion, respondents were keen to con-
vey that they considered eating disorders as a mental illness
and this was often communicated within the context of
mental illness being something that was not contagious or
could be contracted or learned from a website. For example:
Response 1: the mental components of an ED can never be
learnedby a website. They are horrible. Therefore, you
cannot learn how to get an ED. It just isnt possible. Its
like saying you can learn how to be schizo-
phrenic, really …’
Response 10: You can take away websites if you try hard
enough but that will never ever prevent or solve the prob-
lem of a MENTAL ILLNESS that is the reason they exist
in the first place.
Response 38: You certainly cannot learn how to have a
mental illness. You cant teach yourself how to be
depressed, schizophrenic or anorexic.
Response 74: An eating disorder is a mental illness. you
dontgeta mental illness from visiting a website.
Response 117: its extremely hard to catchan ED (I
couldnt find a better word for catch) Its not like a cold
or the flu. Its not viral or bacterial. Its deadly and
Table 1. Summary of the findings.
Higher-order theme Sub-theme Example verbatim quote
1. Eating disorders are mental illnesses and
websites do not cause mental illness
An eating disorder is a mental illness. you dontgeta mental
illness from visiting a website
2. Pro-anorexia websites and eating disorders
are more than wanting to be thin
Residents and visitors Anorexia is not just about wanting to be thin, its about wanting
to have control over some part of your life.”“those who just come
here for tips/crash diets/learn to be ana/etc usually make very few
posts, ask about tips and diets for prom/wedding/vacation, and vanish
from the site.why? because they just learnedhow to starve off a
few pounds and dont really have EDs/lied about having one.
3. Eating disorders develop regardless of
pro-anorexia websites
The problem is the
user, not the site
i would have an ED whether this site was here or not.”“It can trigger
a pre existing disorder but it cant create something thats not there.
4. Pro-anorexia sites do not cause eating disorders
but they may trigger or encourage them
5. Pro-anorexia sites provide support Were all smart people, we all know the risks that we take with our
health. That is why we dont blame something like !!!. I dont think
any of us blame anybody but ourselves. This place has saved my
life Were it not for some of the advice Ive gotten, I probably would
be in the hospital from a major OD [over dose] on diet pills
ISSUES IN MENTAL HEALTH NURSING 867
embedded in our brains until we find the right help or
die, basically.
Response 131: People cannot get an ED from a website.
EDs are a mental illness that doesnt happen overnight,
sometimes it takes years to develop. Now can she learn
tips an tricks on here? Sure, BUT she cannot DEVELOP
an eating disorder merely by visiting this website.
Response 147: I second this. Its easier for people to blame
sites like !!! for causing an ED rather than looking at the
underlying causes. Websites dont cause a mental illness.
Respondents also drew the distinction between restricted
eating and mental illness. For example:
Response 19: They may be starving themselves, but theresa
way between just starving, and actually being mentally ill.
Response 153: Used to be a member of the pro-ed facebook
pages and girls would IM [in box message] me all the time
about my magic diet and get disgruntled when I told them
it involved a mental disorder. Losing ten pounds for prom
is not anorexia.
And one response was particularly emotive:
Response 120: IT IS A MENTAL ILLNESS, YOU DONT
CHOSE ANYTHING. SHE ALREADY WAS ANOREXIC
BUT YOU WERE TO DUMB TO NOTICE AND
ACTUALLY HELP HER.
Pro-ana websites and eating disorders are more than
wanting to be thin
Almost as an extension of the respondents view that eating
disorders are a mental illness and are not something that
How does pro-anorexia
website use contribute to
eating disorders?
Eating
disorders are
mental
illnesses and
websites do
not cause
mental illness
Pro-anorexia
websites and
eating disorders
are more than
wanting to be
thin
Eating disorders
develop regardless
of pro-anorexia
websites
Residents
and visitors
The problem
is the user,
not the site
Pro-anorexia sites
don’t cause eating
disorders, but they
may trigger of
encourage them
Pro-anorexia
sites provide
support
Figure 1. Conceptual model of how pro-anorexia website use contributes to eating disorders.
868 C. E. HILTON
can be learned or contagious, were also discussions around
anorexia and disordered eating being more than the desire
to be thin. For example, respondents talked about the notion
of control, jealousy of others and as a form of escape from
difficult emotions and experiences. This was discussed
within the context of how the website could not contribute
to an exclusive and universal need of site-users to be thin
because eating disorders were considered to manifest for
much broader and additional reasons. Indeed, the desire for
thinness was reported for some as secondary to the need for
control, for example:
Response 20: No a website can not create a disorder. I know
for me in my life this is the only thing i have control of.
Response 29: Im going to be brutal here. I love !!!, but we
all know exactly what we are doing with this. When we
come to !!!, we know were choosing hell. Were choosing
slow death. Were choosing illness. Were choosing pain.
!!! helps us find ways to hide that pain and achieve the
thinness that we crave and the control we so desper-
ately need.
Response 30: The thing most people dont realise is that ED
isnt usually about body image alone. For me, its
about control.
Response 31: Anorexia is not just about wanting to be thin,
its about wanting to have control over some part of
your life.
Response 31: My ED never even started with me wanting to
lose weight, it started with my jealousy over others which
manifested into an issue about food.
Response 61: I never "learnedto have ana/bulemia. I dont
think that is possible. In my life it has always been an
escape/a way to deal with feelings that I really did not
want to think about.
Sub-theme: Residents and visitors
Respondents identified with two types of site-user: those who
visited regularly and identified with having an eating disorder
(residents) and those who visited for a brief amount of time
perhaps to gain dieting tips for weight loss (visitors):
Response 17: those who just come here for tips/crash diets/
learn to be ana/etc usually make very few posts, ask
about tips and diets for prom/wedding/vacation, and van-
ish from the site. why? because they just learnedhow to
starve off a few pounds and dont really have EDs/lied
about having one.
Response 19: of course anorexia seems like a perfect diet, but
when theyve lost the few pounds, the wannas, then they dis-
appear from the site and we never hear from them again.
Response 27: (i hate people that DECIDE to be ana) To me
its more like a religion.
Some respondents even referred to the site as home
to them:
Response 57: this place is my home. its the reason
im alive.
Response 146: I find this a bit offensive [the accusation of
the pro-ana site causing disordered eating]. !!! is like my
second home where I can feel safe talking to people that
understand my issues.
Eating disorders develop regardless of pro-ana websites
There was a considerable discussion around the notion that
eating disorders were something that was independent of pro-
ana website use. Respondents considered that individuals who
sought out the site were likely to have disordered eating
regardless of their accessing the site and as an extension of
what had been discussed within the context of eating disorders
being considered a mental illness, respondents re-affirmed that
pro-ana sites cannot cause eating disorders. For example:
Response 18: There is no way a website can cause an ED.
The vast majority of people who come here have had prob-
lems loooooong before they found a website.
Response 25: No, a website cant make you anorexic. If a
person decides to starve themselves they are going to do it
whether or not they have a website about it or not.
Response 34: a site cant give a ed, you give it to yourself, a
site is just a site,
Response 58: i would have an ED whether this site was here
or not.
Response 134: Washing my hands a million times doesnt
give me OCD. Its the symptom of the problem. Not the
problem itself.
Pro-ana sites dont cause eating disorders but they may
trigger or encourage them
In addition to commentary that demonstrated opinions that
eating disorders developed regardless of whether someone
accessed a pro-ana site or not, views were also expressed
that acknowledged the role of such sites in facilitating the
potential for disordered eating. Often, users would express
an awareness of the risks of site-use in terms of maintaining
an eating disorder and delaying treatment but argued that
this was an informed choice. For example:
Response 4: I agree that sites like this cant give someone
an eating disorder or any mental illness, but I do think
they can make someone with an ED worse. I know when I
was recovering I stayed away from all sites like this. Now
Im trying to lose weight again by unhealthy methods
(drastic calorie cutting) and I have came to !!! and other
sites for thinspiration and to talk to like minded people. I
know they can make me worse, btu thats why I chose to
be here now.
Response 5: Maybe it could bring something underlying in
themselves, out. Thats the most that this site could do.
Nothing can give you and ED in my opinion, but like the
person in above me I do think that this site could make
someones ED worse.
Response 12: I definitely agree with you. Sites like this can
bring out the feelings you might already have about
ISSUES IN MENTAL HEALTH NURSING 869
yourself and make them more prominent than they might
have been before.
Response 29: Im going to be brutal here. I love !!!, but we
all know exactly what we are doing with this. When we
come to !!!, we know were choosing hell. Were choosing
slow death. Were choosing illness. Were choosing pain.
!!! helps us find ways to hide that pain and achieve the
thinness that we crave and the control we so desperately
need. Anorexia and bulimia are horrible illnesses. They kill
and they destroy lives. But sometimse life sucks so much
that anorexia becomes the only way to escape, and so even
though I know its wrong and I know exactly what addic-
tion Im getting myself in to, I come here because I want
my addiction. I dont know that !!! can ever really GIVE
someone an eating disorder, but it can make pretty certain
that you wont go into recovery anytime soon. We all
know, and we choose hell.
Response 63: It can trigger a pre existing disorder but it
cant create something thats not there.
Response 142: you cant learn an ed but this website is defin-
itely the finger on the trigger if the gun is there in the
first place.
And the theme of mental illness was highlighted again
within the context of the site triggering or encouraging eat-
ing disorders:
Response 90: Does going to a mental institution make you
crazy? No, but it does heighten your awareness of your
issues because youre exposing yourself to other disordered
minds, and this can worsen it.
The role of the site in terms of encouraging eating disor-
ders through normalising the behaviours was also raised:
Response 101: MMmm, I dont think this site can cause an
ED in anyone but I definitely think the site can encourage
it. Like having this whole forum and all these members
with EDs just kind of makes it seem like a normal thing, it
kind of takes the big deal out of anorexia.
Sub-theme: The problem is the user, not the site
Almost concurrent with discussions about pro-ana sites act-
ing as a trigger for or encouraging eating disorders, was
commentary that suggested the problems associated with
eating disorders and pro-ana websites were as a consequence
of the user, not the site itself. Respondents spoke of the role
of autonomy and personal accountability in deciding
whether to access the site:
Response 50: Were all smart people, we all know the risks
that we take with our health. That is why we dont blame
something like !!!. I dont think any of us blame anybody
but ourselves.
Response 51: I personally think that people who blame !!!
(or any other ED site) are just using it as a scape goat.
You can blame whomever you want, but the problem lies
with the unhealthy individual, not the website.
Response 128: No. If a store lets you buy a gun or knives,
is it to blame if you killed someone? Basically !!! is the
store. In the end, its our choice. We cant blame a web-
site for causing an ED.
Response 148: Thats ridiculous. BUT if it does, thats the
persons fault who comes here. And those people need to
take responsibility for their own actions, nobody makes
somebody go on a site, they choose to.
Pro-ana sites provide support
In contrast to an awareness of the risks involved in access-
ing pro-ana sites, users also expressed how the support they
received from other users was considered invaluable. Site
access provided users with a safe place to communicate with
like-minded others and generated a sense of community,
solidarity and shared understanding that was otherwise lack-
ing in their lives. We also see the term homeused again
within the context of the role of pro-ana sites provid-
ing support:
Response 1: I find this site as an outlet for my emotions,
and an escape. Im starting recovery, too, and I still will be
here, not to learnto be sick.
Response 3: No !!! is like a place for us to gather and talk,
about our emotions, feelings ups and downs and ever so
much more. Its really upsetting when people claim this site
to be a site that encourages EDs; clearly this is home to
may people. Some may not think so but true sufferers of
anatake this as the only place they will be treated fairly
and with out being judged for what is going on with them.
Response 15: This place has saved my life Were it not for
some of the advice Ive gotten, I probably would be in the
hospital from a major OD on diet pills.
Response 16: I dont believe a site can cause an eating dis-
order. I have only been here a week if that and already I
feel welcomed and not judged in anyway. I think websites
like this provide a haven from criticism that people who
do not understand because they havent been through it
cant provide.
Response 19: If it wasnt for !!!, I would a lot more miser-
able than I am now, because of the lovely people who talks
to me and cares.
Response 23: to people who dont have an ED these sites
mean absolutely nothing, most of them dont even know
about them. I truly think that these sites are a saviour to peo-
ple that already have underlying problems and seek out some
sort of refuge and comfort in the fact that other people are
going through the same thing. I know im thankful …’
Response 47: This is rubbish [the accusation of the site
causing disordered eating]. I think this site is inspirational.
Ive never felt better understood and I have just joined a
couple weeks ago. Thanks for the support !!!.
Response 68: This website does not give people ed it gives
people someone to talk to when there is none else to
talk to.
870 C. E. HILTON
Response 69: you dont get an ED from being around people
that have it. u get it from feeling inadequate in some way-
or at least i did. like im never good enough for my dad to
be proud of me and now being on this site i just have peo-
ple to talk to who understand me more than others in
my life.
Response 76: This is a place to discuss and to understand,
for people to finally talk to people going through similar
things, the realisation that you.are.not.alone, you are not
abnormal and you can do it, it is not about causing disor-
ders or pushing people into them, it is about support.
Response 114: Websites do not give people eating disorders.
Eating disorders usually take years to develop. These web-
sites provide support for those of us who have eating dis-
orders. We would be anorexic whether this site was here
or not. With sites like this, we have others to relate to, and
all people want to do is take that away from us.
Response 115: Im fond of this website, and not because it
influencesme to have anorexia but b/c this is a commu-
nity that understands what im going through. Most of the
ppl [people] i know (I dont mean here in this website)
just dont get it. They think something totaly different
about what they call beautyand what I call beauty”’
Response 132: oh god no .poor thing though, sorry about
your friend but to me, it helps me feel more "normal"
like im not alone in this constant battle.
Discussion
Previous studies have provided insight into the interpret-
ation and potential impact of the content of pro-ana web-
sites (e.g., Brotsky & Giles, 2007; Csipke & Horne, 2007;
Mulveen & Hepworth, 2006) and a content analysis of pro-
ana websites has called for a better understanding of the
impact of sites on users (Borzekowski, Schenk, Wilson, &
Peebles, 2010). To the authors knowledge the current study
is the first to specifically explore user views regarding the
role of pro-ana websites in causing eating disorders by utilis-
ing naturally occurring data that was purposely targeted
towards this debate. Respondents expressed strong beliefs
that eating disorders were representative of mental ill-health
that pro-ana websites and eating disorders should be consid-
ered as more than simply wanting to be thin, and perhaps
because of this, demonstrated resentment towards those who
may access pro-ana sites temporarily for guidance on
extreme weight loss. The view that eating disorders would
develop regardless of whether pro-ana sites were accessed or
not, was also demonstrated within the data. However, web-
site users recognised that access may trigger or encourage a
predisposition to disordered eating. The role of autonomy
and personal accountability for website use reflected a
shared understanding and awareness of the potential risk of
pro-ana sites perpetuating or worsening disordered eating
patterns. Yet, the need for a sense of community, a safe
environment and support that was otherwise lacking in their
lives negated the awareness of these risks in favour of con-
tinued site access.
The present study is not without its limitations. Whilst
the use of naturally occurring data should be a considered a
strength (predominantly because data generation was free of
researcher influence), regrettably this also means that partic-
ipants could not be contacted. It would have been poten-
tially valuable to gain some accurate demographic
information, establish if the participants had been formally
diagnosed with an eating disorder and explore some of the
discussion contributions in more depth, for example. This
may have also generated opportunities to signpost partici-
pants to alternative sources of support and treatment.
Nevertheless, the findings of the current study present some
novel insights into the role of pro-ana websites in the main-
tenance of eating disorders and these are worthy
of attention.
The current edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5; American Psychiatric
Association, 2013)recognisesAnorexiaNervosaasaper-
sistent restriction of energy intake leading to significantly
low body weight, an intense fear of weight gain, of becom-
ing fat or persistent behaviour that interferes with weight
gain and a disturbance in the way body weight or shape is
experienced and/or lack of recognition of the seriousness
of the current low body weight. The International
Statistical Classification of Diseases and Related Health
Problems, tenth revision (ICD-10; World Health
Organisation, 1992)providesspecificdetailforadiagnosis
of Anorexia Nervosa that includes a body weight of at
least 15% below the normal or expected weight for age
and height, self-induced weight loss by avoidance of fat-
tening foods, a self-perception of being too fat, with an
intrusive dread of fatness, which leads to a self-imposed
low weight threshold and a widespread endo-
crine disorder.
The narrow emphasis of DSM-5 and ICD-10 upon
medical and physiological indicators, and lack of attention
to those that are more demonstrable of the psycho-social
complexity of eating disorders as described in the current
study is quite apparent. For example, site-users in the
current study attributed their disordered eating to a
feeling and method of control, the consequence of jealousy
of others and as a form of escape from difficult emotions
and experiences. These broader considerations are likely
to be missed if adopting a limited medical model approach
to the assessment of eating disorders as presented in
DSM-5 and ICD-10. This demonstrates why such
diagnostic tools are typically considered ill-fitted to psy-
chologically oriented assessment and treatment (e.g.,
Elkins, 2009).
It is perhaps because of the complexity of the aetiology
and course of eating disorders that several explanatory mod-
els have been proposed including medical, psycho-social,
socio-cultural and feminist perspectives (see Fox, Ward &
ORourke, 2005 for a tabulated summary). A pro-ana per-
spective would argue that eating disorders and associated ill-
ness are not something that should be remedied through
medical or psychosocial treatment (Fox et al., 2005).
However, despite this, in the current study, several
ISSUES IN MENTAL HEALTH NURSING 871
individuals conveyed the importance of eating disorders
being considered as a mental illness, perhaps also in an
effort to evoke empathy towards their condition rather than
invite any further criticism similar to that of the initial
accusatory message that was posted on the website.
In somewhat of a contrast to the notion of eating disor-
ders being considered as mental illnesses, respondents also
spoke of pro-ana access as a lifestyle choice. Indeed, one
respondent referred to their anorexia as being more like a
religion (Response 27). Several site-users disclosed that they
were aware of the risks associated with pro-ana site access.
That it was likely that the information contained within
them would not only trigger disordered eating patterns and
anorexia in those who were predisposed but that their own
recovery was challenged too. This dichotomous perception
of pro-ana sites reflecting either an illness or a chosen life-
style has been recognised previously (Strife & Rickard,
2011)andpresentsapersistentchallengefortreatmentand
recovery. The notion of a discrepancy between knowledge/
attitudes and behaviour has also been recognised within
the psychology literature as early as the 1950s and was
coined cognitive dissonance (Festinger, 1957). Whilst this
is now considered a dated and classic contribution to
explaining behaviour, this and early theoretical contribu-
tions to understanding health behaviours such as the health
belief model (HBM, e.g., Rosenstock, 1974)seemtohave
an enduring and contemporary relevance to eating disor-
ders that has also been demonstrated by the cur-
rent findings.
For example, individual perceptions of susceptibility to
developing a condition (e.g., anorexia), severity of the condi-
tion, benefits, barriers, cues to action and self-efficacy that
comprise the HBM all have relevance to the findings of the
current study. The dichotomy between understanding eating
disorders as a mental illness or lifestyle choice maps well
onto the HBM because despite respondents in the current
study reporting that they were aware of their susceptibility
to developing a chronic disordered eating condition, and
that the consequences of this were severe; the perceived ben-
efits of engaging with pro-ana as a lifestyle choice and the
sense of support and community that comes with it were
enough to outweigh these health risks. The current findings
would indicate that over time, prolonged engagement with
pro-ana communities strengthens this perception of per-
ceived benefits outweighing risks, normalises disordered eat-
ing, thereby reducing the self-efficacy and cues to action
needed to seek treatment. Therefore, from a population and
broad condition perspective, utilising the HBM to explore
the decisional processes associated with pro-ana site access,
their contribution to the maintenance of eating disorders
and whether treatment is sourced may prove helpful in
advancing knowledge and informing approaches to treat-
ment in this respect.
Indeed, utilising the HMB as a method of deductively
interpreting 34 interviews with men and women who expe-
rienced disordered eating has revealed the critical role of
social support for management and treatment (Akey,
Rintamaki, & Kane, 2013). The authors also echo the
concerns raised previously of the limitations of a medical-
ised and clinical intervention approach to address the psy-
cho-social complexity of disordered eating. Therefore,
despite the potential utility of the HMB for better under-
standing eating disorders, it is also worth acknowledging
the importance of avoiding an overly theoretical approach
to advancing knowledge regarding the treatment of illness.
What is perhaps of equal or greater importance is support-
ing clinicians to develop evidence-based therapeutic clinical
skills to support individuals and families through the pro-
cess of recovery.
Whilst behaviour change ambivalence is something that
is commonly observed (Miller & Rollnick, 2002,2012), the
draw of the perceived benefits of anorexia directly opposes
treatment and recovery. This is perhaps best demonstrated
by Respondent 29 when they stated that even though I know
its wrong and I know exactly what addiction Im getting
myself in to, I come here because I want my addiction. From
this perspective, drawing from contributions to clinical
practice for the treatment of addictive behaviours may
prove a valuable transfer of knowledge. For example, a
recent systematic review (Macdonald, Hibbs, Corfield, &
Treasure, 2012) would suggest that motivational interview-
ing (MI)a person-centred and collaborative approach, ini-
tially developed to treat drug and alcohol problems and
specifically intended to help a person explore and resolve
ambivalence and enhance readiness to change (see Miller
and Rollnick, 2002,2012) is suited to the treatment of
eating disorders.
However, for the adult treatment of anorexia nervosa,
the recently published UK guidance recommends eating dis-
order focussed cognitive behavioural therapy (CBT-ED),
Maudsley Anorexia Nervosa Treatment for Adults
(MANTRA) or specialist supportive clinical management
(SSCM) (NICE, 2017). For children (012 years) and
younger people (1317 years), anorexia nervosa focussed
family therapy (FT-AN) is recommended. The guidance
recognises that the current evidence-base for the most
appropriate treatment of eating disorders is problematic.
For example, we are advised that there is little evidence for
the psychological treatment of people with binge eating dis-
order and the impact of such therapy upon remission is
unclear (NICE, 2017). Similarly, the guidance advises that
despite the wide range of treatments available for anorexia
nervosa, they are often ineffective and that there is a high
risk of relapse (NICE, 2017). With this in mind, it is diffi-
cult to understand how the recommendations for
approaches to treatment have been derived. Indeed, in
response to the lack of evidence regarding appropriate
treatments for children and young people, the NICE (2017)
guidance recommends that eating disorder-focussed family
therapy could be compared with individual CBT-ED and
self-help such as Internet or guided self-help. However,
there is little or no rationale for this and the increasing role
of social media, the Internet and pro-ana websites and their
potentially detrimental impact on health and well-being is
not recognised. This is despite evidence from a growing lit-
erature that demonstrates the implications of access to these
872 C. E. HILTON
for the maintenance, treatment and self-management of
health and illness (e.g., Bardone-Cone and Cass, 2007;
Bates, 2015; Bull, Gaglio, Mckay, & Glasgow, 2005;
Hilton, 2016).
Implications for practice
A medical and clinical intervention-only approach fails to
represent the complexity of eating disorders, those who con-
sider them as a lifestyle choice or who are ambivalent about
treatment and it has been argued that diagnostic tools such
as the DSM-5 poorly reflect the psycho-social and clinical
reality of eating disorders (Fairburn & Cooper, 2011).
Coupled with the emergence of pro-ana websites, social
media and online communities, clinicians are presented with
complex treatment challenges. For example, for those who do
seek treatment, the implications of the disproportional time
spent with a clinician versus that which may be spent engag-
ing with highly accessible Internet sources such as pro-ana
websites poses risk to the treatment process (Hilton, 2016).
This reflects a very contemporary issue within clinical and
health care contexts and there is a need to better understand
the role and impact of Internet sources and social media
upon helping or hindering treatment and well-being more
generally. The current research has indicated that for those
with disordered eating who access pro-ana resources, clini-
cians would benefit from exploring specifically yet collabora-
tively with individuals, what the perceived role and impact of
this is for their desire to maintain or discontinue disordered
eating patterns. Developing a therapeutic alliance between
patient and clinician has been consistently demonstrated to
be critical to treatment outcomes (e.g., Martin, Garske, &
Davis, 2000) and building an empathic and trusting relation-
ship should be integral to the treatment process and may also
facilitate family engagement (Plath, Williams, & Wood,
2016), support shared decision-making within mental health
settings, impact upon potential perceived power imbalances
(Stacey, Felton, Morgan, & Dumenya, 2016) and protect
nurses from harm by enhancing authentic, empathic thera-
peutic relationships (Wright & Schroeder, 2016). However,
the recently published NICE (2017) guidance only refers to
the importance of developing therapeutic alliance within the
first phase of therapy which appears somewhat limited given
the critical importance of this alliance for treatment outcomes
(e.g., Hilton & Johnston, 2017).
With the rise in manualised approaches to therapy (e.g.,
Waterman-Collins et al., 2014)andsimilarworkthat
attempts to identify standardised ingredients of behaviour
change through the use of taxonomies (e.g., Abraham &
Michie, 2008; Michie et al., 2011), attention to all-import-
ant interpersonal processes such as the expression of
empathy and building trust and therapeutic alliance have
never been more important for health care practice.
Arguably, health care policy and scientific literature are
heavily focussed upon the what to do at the expense of the
how to do it. Consequently, there has been a call for shift-
ing the focus from the what to the how and for training
programmes to better support healthcare practitioners to
develop proficiency in both knowledge (what should be
done) and skills (how to do it) through appropriate compe-
tency requirements, approaches to assessment (e.g., both
skills and knowledge based) and continued professional
development (Hilton & Johnston, 2017; Hilton, Lane, &
Johnston, 2016).
It has been demonstrated that MI may prove a valuable
approach in helping those who are particularly ambivalent
about treatment and recovery to enhance their perceived
readiness and motivation to change disordered eating
(Macdonald et al., 2012). It makes intuitive sense that a
therapeutic method designed specifically to support ambiva-
lent individuals through change may be a valuable treatment
option (at least in the early stages) for those diagnosed with
eating disorders that are undecided about treatment. The MI
approach and in particular the use of the decisional balance
(pros and cons of undergoing treatment) (see Miller &
Rollnick, 2002,2012) may also assist with exploring and
resolving the typically antagonistic nature of individuals
wanting to be well yet embracing their eating disorder,
thereby supporting individuals to engage with treatment.
However, despite the lack of evidence for treatment success,
cognitive-behavioural approaches seem to be favoured
(NICE, 2017). Absence of evidence does not necessarily indi-
cate evidence of absence and given the levels of uncertainty
regarding appropriate treatment options for eating disorders,
there has never been a more critical time to conduct well-
funded trials and research that are capable of capturing the
qualitative and process-related aspects of therapeutic
encounters as well as treatment outcomes. The problematic
advocacy of CBT in the absence of additional treatment evi-
dence is not unique to eating disorders. For example, the
need for a shift away from a restrictive one size fits all
approach to the treatment of obesity (Johnston, Hilton, &
Lane, 2017) and the limited focus of NICE guidance for the
recognition and management of depression in adults (NICE,
2009) has also been encouraged (McQueen, 2009). It is then,
perhaps that clinicians will be better positioned to under-
stand the complexity of disordered eating. The current study
has revealed the integral role of pro-ana sites for maintain-
ing eating disorders and how the online community fuels
the discrepancy between seeking wellness yet embracing ill-
ness. Where relevant, empathic conversations with patients
about the perceived role of pro-ana sites in the maintenance,
treatment and recovery of their eating disorder could be
integrated into routine consultations. Doing so may help the
patient and practitioner to identify what aspects of pro-ana
site use may maintain disordered eating behaviours and
pose particular threats to recovery. There may also be
opportunities to identify collaboratively, if there are any
aspects of pro-ana site use that may also facilitate recovery
and thereby used to inform mutually agreed treatment plans
through a process of genuine shared decision-making.
Acknowledgements
The author wishes to thank Sarah Murphy for her role in generating
the data corpus.
ISSUES IN MENTAL HEALTH NURSING 873
ORCID
Charlotte Emma Hilton http://orcid.org/0000-0001-6034-118X
References
Abraham, C., & Michie, S. (2008). A taxonomy of behaviour change
techniques used in interventions. Health Psychology,27(3), 379387.
Akey, J. E., Rintamaki, L. S., & Kane, T. L. (2013). Health belief model
deterrents of social support seeking among people with eating disor-
ders. Journal of Affective Disorders,145(2), 246252.
American Psychiatric Association (2013). Diagnostic and Statistical
Manual of Mental Disorders: (DSM-5) (5th ed.). Arlington, VA:
American Psychiatric Publishing.
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. The International Journal of Eating
Disorders,40(6), 537548.
Bates, C. F. (2015). I am a waste of breath, of space, of time:
Metaphors of self in a pro-anorexia group. Qualitative Health
Research,25(2), 189204.
Boero, N., & Pascoe, C. J. (2012). Pro-anorexia communities and
online interaction: Bringing the pro-ana body online. Body and
Society,18(2), 2757.
Borzekowski, D. L. G., Schenk, S., Wilson, J. L., & Peebles, R. (2010).
E-Ana and e-Mia: A content analysis of pro-eating disorder Web
sites. American Journal of Public Health,100(8), 15261534.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology.
Qualitative Research in Psychology,3(2), 77101.
Braun, V., & Clarke, V. (2013). Successful qualitative research: A prac-
tical guide for beginners. London, UK: Sage.
Braun, V., Clarke, V., & Terry, G. (2014). Thematic analysis. In: P.
Rohleder & A. C. Lyons (Eds.), Qualitative research in clinical and
health psychology (pp. 95114). London, UK: Palgrave Macmillan.
British Psychological Society (BPS). (2013). Ethics Guidelines for
Internet-Mediated Research. Retrieved from http://www.bps.org.uk/
system/files/Public%20files/inf206-guidelines-for-internet-mediated-
research.pdf (Accessed July 12, 2017).
Brotsky, S. R., & Giles, D. (2007). Inside the pro-anacommunity: A
covert online participant observation. Eating Disorders,15(2),
932007.
Bull, S. S., Gaglio, B., Mckay, H. G., & Glasgow, R. E. (2005).
Harnessing the potential of the internet to promote chronic illness
self-management: Diabetes as an example of how well we are
doing.Chronic Illness,1(2), 143155.
Christodoulou, M. (2012). Pro-anorexia websites pose public health
challenge. The Lancet,379(9811), 110
Csipke, E., & Horne, O. (2007). Pro-eating disorder websites: Users
opinions. European Eating Disorders Review,15(3), 196206.
Custers, K. (2015). The urgent matter of online pro-eating disorder
content and children: Clinical practice. European Journal of
Pediatrics,174(4), 429433.
Elkins, D. N. (2009). The medical model in psychotherapy: Its limita-
tions and failures. Journal of Humanistic Psychology,49(1), 6684.
Fairburn, C. G., & Cooper, Z. (2011). Eating disorders, DSM-5 and
clinical reality. The British Journal of Psychiatry: The Journal of
Mental Science,198(1), 810.
Festinger, L. (1957). A theory of cognitive dissonance. Stanford: CA:
Stanford University Press.
Fox, N., Ward, K., & ORourke, A. (2005). Pro-anorexia, weight-loss
drugs and the internet: An anti-recoveryexplanatory model of
anorexia. Sociology of Health &; Illness,27(7), 944971.
Harper, K., Sperry, S., & Thompson, K. J. (2008). Viewership of pro-
eating disorder websites: Association with body image and eating
disorders. International Journal of Eating Disorders,41(1), 9295.
Harshbarger, J. L., Ahlers-Schmidt, C. R., Mayans, L., Mayans, D., &
Hawkins, J. H. (2009). Pro-anorexia websites: What a clinician
should know. The International Journal of Eating Disorders,42(4),
367370.
Hilton, C. E. (2016). Unveiling self-harm behaviour: What can social
media site Twitter tell us about self harm behaviour? A qualitative
exploration. Journal of Clinical Nursing,26(1112), 16901704.
Hilton, C. E., & Johnston, L. H. (2017). Health psychology: Its not
what you do, its the way that you do it. Health Psychology Open,
4(2), 2055102917714910 http://journals.sagepub.com/doi/pdf/10.
1177/2055102917714910).
Hilton, C. E., Lane, C., & Johnston, L. H. (2016). Has motivational
interviewing fallen into its own premature focus trap? International
Journal for the Advancement of Counselling,38(2), 145158.
Hoek, H. W., & van Hoeken, D. (2003). Review of the prevalence and
incidence of eating disorders. The International Journal of Eating
Disorders,34(4), 383396.
Jett, S., LaPorte, D. J., & Wanchisn, J. (2010). Impact of exposure to
pro-eating disorder websites on eating behavior in college women.
European Eating Disorders Review,18(5), 410416.
Johnston, L. H., Hilton, C. E., & Lane, C. (2017). Psychological man-
agement in bariatric surgery. In J. Weaver (Ed.), Practical guide to
obesity medicine (pp. 299313). London, UK: Elsevier.
Levine, M. P. (2012). Loneliness and eating disorders. Journal of
Psychology,146(12), 243257.
Lyons, E. J., Mehl, M. R., & Pennebaker, J. W. (2006). Pro-anorexics
and recovering anorexics differ in their linguistic internet self-pre-
sentations. Journal of Psychosomatic Research,60(3), 253256.
Macdonald, P., Hibbs, R., Corfield, F., & Treasure, J. (2012). The use
of motivational interviewing in eating disorders: A systematic
review. Psychiatry Research,200(1), 111.
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the
therapeutic alliance with outcome and other variables: A meta-ana-
lytic review. Journal of Consulting and Clinical Psychology,68(3),
438450.
McQueen, D. (2009). Response to the NICE clinical guideline on
depression. The British Psychoanalytic Council. Retrieved from
https://www.bpc.org.uk/sites/psychoanalytic-council.org/files/NICE-
McQueen-web.pdf (Accessed July 12, 2017).
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing:
Preparing people for change (2nd ed.). London, UK: Guilford Press.
Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping
people change (3rd ed.). London, UK: Guilford Press.
Michie, S., Ashford, S., Sniehotta, F. F., Dombrowski, S. U., Bishop, A.,
& French, D. P. (2011). A refined taxonomy of behaviour change
techniques to help people change their physical activity and healthy
eating behaviours: The CALO-RE taxonomy. Psychology and Health,
26(11), 14791498.
Mulveen, R., & Hepworth, J. (2006). An interpretive phenomenological
analysis of participation in a pro-anorexia internet site and its rela-
tionship with disordered eating. Journal of Health Psychology,11(2),
283296.
National Institute for Health and Care Excellence (NICE). (2004).
Eating disorders in over 8s: Recognition and management. Retrieved
from https://www.nice.org.uk/guidance/cg9/resources/eating-disor-
ders-in-over-8s-management-27103918021 (Accessed July 12, 2017).
National Institute for Health and Care Excellence (NICE). (2009).
Depression in adults: Recognition and management. Retrieved from
https://www.nice.org.uk/guidance/cg90/resources/depression-in-adults-rec-
ognition-and-management-pdf-975742636741 (Accessed July 12, 2017).
National Institute for Health and Care Excellence (NICE). (2017).
Eating disorders: Recognition and treatment. Retrieved from https://
www.nice.org.uk/guidance/ng69/resources/eating-disorders-recogni-
tion-and-treatment-pdf-1837582159813 (Accessed July 12, 2017).
Norris, M. L., Boydell, K. M., Pinhas, L., & Katzman, D. K. (2006).
Ana and the Internet: A review of pro-anorexia websites.
International Journal of Eating Disorders,39(6), 443447.
Plath, D., Williams, L. T., & Wood, C. (2016). Cliniciansviews on par-
ental involvement in the treatment of adolescent anorexia nervosa
Eating Disorders,24(5), 393411.
Rosenstock, I. M. (1974). Historical origins of the health belief model.
Health Education Monographs,2(4), 328335.
874 C. E. HILTON
Smink, F. R. E., van Hoeken, D., & Hoek, H. W. (2012). Epidemiology
of eating disorders: Incidence, prevalence and mortality rates.
Current Psychiatry Reports,14(4), 406414.
Spall, S., & Stephen, F. (1998). Peer debriefing in qualitative research:
emerging operational models. Qualitative Enquiry,4(2), 280292.
Stacey, G., Felton, A., Morgan, A., & Dumenya, J. (2016). A critical
narrative analysis of shared decision-making in acute inpatient men-
tal health care. Journal of Interprofessional Care,30(1), 3534.
Strife, S. R., & Rickard, K. (2011). The conceptualization of anorexia:
The pro-ana perspective. Journal of Women and Social Work,26(2),
2132017.
Waterman-Collins, D., Renwick, B., Lose, A., Kenyon, M., Serpell, L.,
Richards, L., Schmidt, U. (2014). Process evaluation of the
MOSAIC trial, part I: Therapist experiences of delivering two psy-
chological therapies for treatment of anorexia nervosa. European
Eating Disorders Review,22(2), 122130.
World Health Organisation. (1992). ICD-10: The ICD-10 Classification
of mental and behavioural disorders: Clinical descriptions and diag-
nostic guidelines. Geneva, Switzerland: World Health Organisation.
Wright, K. A. R. E. N., & Schroeder, D. O. R. I. S. (2016). Turning the
tablesThe vulnerability of nurses treating anorexia nervosa
patients. Cambridge Quarterly of Healthcare Ethics,25(02), 219227.
ISSUES IN MENTAL HEALTH NURSING 875
... In recent years, the spread of the use of the internet and social networks (Mascheroni & Holloway, 2019) among the youngest could have interacted with the exacerbation of a psychopathological disorder (Lai et al., 2017;Tonioni et al, 2014Tonioni et al, , 2018, as in the case of an eating disorder (Hilton, 2018). Although this aspect still needs to be adequately investigated, the communication with peer group members appears to be the most important motivation for using social networking sites compared to eating behaviors. ...
... The discussion in the Anorexia group, in fact, would not seem to be moved by the same social need for approval as the discussion in the Pro-Ana group. The participants of Pro-Ana group are not inclined to speak of anorexia as a disorder, but instead they consider pro-ana as a lifestyle choice or, in some cases, referred to their anorexia as being more like a religion (Hilton, 2018). This particular differentiation between Pro-Ana group and Anorexia group members has important clinical and therapeutic implications, reflecting the importance to create a strong alliance also with the non-compliant aspects of the patients (Hilton, 2018). ...
... The participants of Pro-Ana group are not inclined to speak of anorexia as a disorder, but instead they consider pro-ana as a lifestyle choice or, in some cases, referred to their anorexia as being more like a religion (Hilton, 2018). This particular differentiation between Pro-Ana group and Anorexia group members has important clinical and therapeutic implications, reflecting the importance to create a strong alliance also with the non-compliant aspects of the patients (Hilton, 2018). ...
Article
The study aimed to examine the different contents of posts published in an online community for eating disorders among four groups (Pro-Ana, Anorexia, Bulimia, and Binge Eating Disorder). The hypothesis was that Pro-Ana group members would have a greater propensity to deny the negative aspects of their eating disorder and a greater social adherence to their own blog community compared to the other groups. 1791 posts, collected from December 2018 to March 2019, were analyzed using quantitative analyses of the text through T-LAB software (version T-Lab Plus 2020). The cluster analysis of the text showed that Pro-Ana group appears to be more represented by “social sharing” cluster compared to the other groups, exhibiting a greater tendency to exchange social support about their eating behaviors. Factorial space analysis reported that Pro-Ana people tend to be less capable to provide realistic representation of their eating disorder than the other groups. Finally, Pro-Ana group members showed a greater social adherence in terms of satisfaction ratings (ratio “likes”/“views” to each post) compared to the other groups.
... These studies have explored adolescent exposure to these websites, personal profiles related to access to social network, as well as pro-ana accounts on Twitter [18,21,26,28]. Other more social, aspects, linked to communication and language, have been explored in a recent study on language and information used on this website [29][30][31]. The relationship between a problematic use and abuse of the Internet and eating behaviors in adolescence has been investigated, as well as negative online support in the case of pro-anorexia websites [11,14,22]. ...
... These studies have explored teenagers' exposure to these websites, personal profiles related to popular access to social network, as well as pro-ana accounts on Twitter [18,21,26,28]. Other more social aspects, linked to communication and language, have been explored in a recent study on language and information used on this website [29][30][31]. The relationship between a problematic use and abuse of the Internet and eating behaviors in adolescents has been investigated, as well as negative online support in the case of pro-anorexia websites [11,14,22]. ...
... This is in line with anti-recovery, because these blogs, communities, and/or websites reject recovery and medical treatment for eating disorders. Another form of resistance involved in these websites is disagreement with psychiatric and psychological treatment [30][31][32][33][34][35]. ...
Article
Full-text available
(1) Background: Teenagers (in particular, females) suffering from eating disorders report being not satisfied with their physical aspect and they often perceive their body image in a wrong way; they report an excessive use of websites, defined as PRO-ANA and PRO-MIA, that promote an ideal of thinness, providing advice and suggestions about how to obtain super slim bodies. (2) Aim: The aim of this review is to explore the psychological impact of pro-ana and pro-mia websites on female teenagers. (3) Methods: We have carried out a systematic review of the literature on PubMed. The search terms that have been used are: “Pro” AND “Ana” OR “Blogging” AND “Mia”. Initially, 161 publications were identified, but in total, in compliance with inclusion and exclusion criteria, 12 studies have been analyzed. (4) Results: The recent scientific literature has identified a growing number of Pro Ana and Pro Mia blogs which play an important role in the etiology of anorexia and bulimia, above all in female teenagers. The feelings of discomfort and dissatisfaction with their physical aspect, therefore, reduce their self-esteem. (5) Conclusion: These websites encourage anorexic and bulimic behaviors, in particular in female teenagers. Attention to healthy eating guidelines and policies during adolescence, focused on correcting eating behavioral aspects, is very important to prevent severe forms of psychopathology with more vulnerability in the perception of body image, social desirability, and negative emotional feedback.
... Estímulos condicionados, embora não sejam necessários para a sobrevivência ou a ameacem, podem exercer importante influência sobre a probabilidade do comportamento (Abib, 2007). Exemplo disso é o caso de pessoas que, sob influência de curtidas e reconhecimento social, fazem postagens de fake news ou de pessoas que, sob influência de grupos digitais, aderem a dietas restritivas como estilo de vida (Hilton, 2018). ...
Article
O presente artigo explora a importância do conhecimento sobre princípios básicos da Análise do Comportamento e de sua difusão para a população, o que consiste em um dos comportamentos mais críticos para a atuação de analistas do comportamento, dada a sua dimensão socialmente relevante. A divulgação desse conhecimento por meio de debates de questões cotidianas pode ser uma forma de alcançar esse público. Para isso, foi tomada como base a estrutura do texto do livro “Ciência no cotidiano: viva a razão, abaixo a ignorância”, que abarca cinco aspectos: 1) explicação do que é o tema; 2) ilustrações com exemplos cotidianos sobre o tema; 3) tecnologias desenvolvidas a partir do conhecimento científico; 4) vantagens decorridas do emprego dessas tecnologias; 5) proteção contra os abusos decorridos por ignorar o tema. Os principais conceitos em torno do comportamento operante foram descritos a partir dessa estrutura.Palavras-chave: Análise do Comportamento; Comportamento operante; Divulgação científica.
... "Bone photography", featuring skeletal images, is deemed beautiful in the pro-ana community, symbolizing allegiance to the pro-ana lifestyle (Bardone-Cone and Cass, 2007). Pro-aners downplay the negative aspects of their eating disorder, viewing pro-ana syndrome as a lifestyle choice or adopting a blinded perspective on anorexia (Carlo et al., 2021;Hilton, 2018). Nonetheless, insights from an individual overcoming pro-ana syndrome shed light on navigating this phenomenon: Don't even try. ...
Article
Purpose This paper aims to in the modern world, possessing an attractive appearance is often considered a highly valued attribute. As such, the perceptions and satisfaction with one’s body are shaped by dominant cultural norms. Adolescents, women in particular, who are heavily influenced by media representations, may tend to have a distorted body image (BI), including adopting extreme dieting methods. This study reviews the adverse effects of excessive weight loss associated with this. Design/methodology/approach The authors searched journals and the internet for relevant literature using the keywords “eating disorders”, “body image” and “weight stigma”. In the case study field, they added papers that considered “nutrition” to identify the link between dieting behaviour and nutrition. From these reviews, the authors ultimately selected 190 articles that appeared to meet their research objectives. The papers cover a range of studies published between 1995 and 2023. Findings Among adolescent girls and young women in their early 20s, there is a social media-driven culture of being extremely thin and petite. Weight stigma puts more pressure on them and makes strange behaviours like pro-ana syndrome a part of the culture. The authors have seen that modern BI standards leave young women vulnerable to eating disorders caused by excessive dieting. Originality/value Adolescence is a time of continuous growth, so balanced nutrition is essential. However, biased societal standards of beauty can push adolescent girls who are sensitive to external gaze into excessive dieting and make eating disorders a culture. This review provides a perspective on the behaviours that should be pursued for a healthy BI.
... With concerns around manualized or highly structured approaches being perceived as 'therapy by numbers' (Hilton et al., 2016), and evidence of limited impact of such approaches (Davies, 2019), it was important to assess how any structure offered by the cubes might be perceived as impacting negatively upon the therapeutic process (all-important therapeutic alliance) and potential client outcomes. This was of particular interest because therapeutic alliance has been consistently demonstrated as being crucial to favorable client outcomes (e.g., Hilton, 2018;Hilton and Johnston, 2017;Horvath and Bedi, 2002;Horvath and Symonds, 1991). Introducing a tool into therapeutic environments risks an over-reliance on 'what is done' in a mechanistic manner rather than 'how it is done' (i.e., therapeutic alliance and interpersonal process). ...
Article
Full-text available
Problematic Internet use has been associated with eating disorders. An increasing number of young adults are using social media, and a variety of content promoting anorexia and bulimia (pro-anorexia and pro-bulimia) has been identified. The aim of this study is to qualitatively analyze this content to understand how it affects individuals with eating disorders or those at risk. Content selection was carried out through non-random intentional sampling and based on the following criteria: the most prominent content on each platform in terms of the number of interactions, created within less than 5 years old, and displaying pro-ana and/or pro-mia content in English or Spanish. In total, 6 digital platforms were analyzed, including 57 resources (videos, images, blog entries, chat messages, PDF files, and group descriptions). The discourse was analyzed using both quantitative and qualitative approaches. The analyzed content includes numerous tips and tricks promoting eating disorders. Additionally, a widespread positive sentiment towards low weight and thinness was observed, while negative sentiments were associated with eating, gaining weight, etc. It has been demonstrated that self-esteem in adolescents and young adults can be affected by social media use, leading to body dissatisfaction that may result in increased use of these platforms with access to pro-anorexia and pro-bulimia content, which can contribute to the development of these disorders. The continuous variation and removal of this content, and the health problems it poses, requires further study of these digital resources and how users access them, in order to establish preventive measures to ensure health in the future.
Article
Background Social media is a relatively new and impactful way to connect millions of people around the world. The intersection of mental health and social media is a poorly studied, yet important area of research. Specifically, with regard to college-aged youth, social media can potentially offer an educational tool to enhance mental health awareness or augment treatment. There is also the risk of disinformation, cyberbullying, and privacy breaches when social media is used for professional purposes by mental health advocates or healthcare professionals. Method The authors of this paper utilized PubMed and Medline databases to review the most recent experimental studies and literature reviews available on the topic of mental health and social media. Results Abstracts and relevant papers were read in full, and information from these studies were cited accordingly. Conclusion The authors conclude that although more research needs to be conducted, social media may offer benefits for mental health awareness, education, and treatment, specifically in populations such as college-aged youth.
Article
Full-text available
Background: Research suggests that direct exposure to suicidal behaviors and acts of self-harm through social media may increase suicidality through imitation and modeling, particularly in more vulnerable populations. One example of a social media phenomenon that demonstrates how self-harming behavior could potentially be propagated is the blue whale challenge. In this challenge, adolescents and young adults are encouraged to engage in self-harm and eventually kill themselves. Objective: This paper aimed to investigate the way individuals portray the blue whale challenge on social media, with an emphasis on factors that could pose a risk to vulnerable populations. Methods: We first used a thematic analysis approach to code 60 publicly posted YouTube videos, 1112 comments on those videos, and 150 Twitter posts that explicitly referenced the blue whale challenge. We then deductively coded the YouTube videos based on the Suicide Prevention Resource Center (SPRC) safe messaging guidelines as a metric for the contagion risk associated with each video. Results: The thematic analysis revealed that social media users post about the blue whale challenge to raise awareness and discourage participation, express sorrow for the participants, criticize the participants, or describe a relevant experience. The deductive coding of the YouTube videos showed that most of the videos violated at least 50% of the SPRC safe and effective messaging guidelines. Conclusions: These posts might have the problematic effect of normalizing the blue whale challenge through repeated exposure, modeling, and reinforcement of self-harming and suicidal behaviors, especially among vulnerable populations such as adolescents. More effort is needed to educate social media users and content generators on safe messaging guidelines and factors that encourage versus discourage contagion effects.
Article
Full-text available
Despite the growth in theoretical understandings of health behaviour and standardised approaches to health interventions (e.g. behaviour change taxonomies), health psychology has paid comparatively less attention to the importance of the implementation processes – ‘how to’ rather than ‘what to’ of such interventions. The clinical and interpersonal skills that often reflect these implementation processes are poorly defined within the health psychology literature. The level of proficiency in such skills expected of Health and Care Professions Council registered practitioner health psychologists is unclear and poorly documented within the UK training requirements. This article explores the potential impact of this and offers some pragmatic solutions.
Article
Full-text available
Since the initial conception of the behaviour change method Motivational Interviewing, there has been a shift evident in epistemological, methodological and practical applications, from an inductive, process and practitioner-focussed approach to that which is more deductive, research-outcome, and confirmatory-focussed. This paper highlights the conceptual and practical problems of adopting this approach, including the consequences of assessing the what (deductive outcome-focussed) at the expense of the how (inductively process-focussed). We encourage a return to an inductive, practitioner and client-focussed MI approach and propose the use of Computer Assisted Qualitative Data Analysis Systems such as NVivo in research initiatives to support this aim.
Article
Full-text available
In bioethics, the concept of vulnerability is applied almost exclusively to research participants and patients. We turn the tables and apply the concept to nurses caring for anorexia nervosa (AN) sufferers. In doing so, and using results from a qualitative research study undertaken in the UK, we show that AN nurses face a significant probability of incurring identifiable harms (inauthentic relationships and nonreciprocal relationships). Some recommendations on how these harms can be avoided or mitigated are given, but further research is needed.
Article
Full-text available
Shared decision-making (SDM) is a high priority in healthcare policy and is complementary to the recovery philosophy in mental health care. This agenda has been operationalised within the Values-Based Practice (VBP) framework, which offers a theoretical and practical model to promote democratic interprofessional approaches to decision-making. However, these are limited by a lack of recognition of the implications of power implicit within the mental health system. This study considers issues of power within the context of decision-making and examines to what extent decisions about patients’ care on acute in-patient wards are perceived to be shared. Focus groups were conducted with 46 mental health professionals, service users, and carers. The data were analysed using the framework of critical narrative analysis (CNA). The findings of the study suggested each group constructed different identity positions, which placed them as inside or outside of the decision-making process. This reflected their view of themselves as best placed to influence a decision on behalf of the service user. In conclusion, the discourse of VBP and SDM needs to take account of how differentials of power and the positioning of speakers affect the context in which decisions take place.
Article
Full-text available
According to recent research on eating disorders, heavy users of pro-anorexia (pro-ana) sites show higher levels of disordered eating and more severe impairment of quality of life than non-heavy users. A better understanding of how pro-ana members self-present in the virtual world could shed some light on these offline behaviors. Through discourse analysis, I examined the metaphors the members of a pro-ana group invoked in their personal profiles on a popular social networking site, to talk about the self. I applied the Metaphor Identification Procedure to 757 text profiles. I identified four key metaphorical constructions in pro-ana members’ self-descriptions: self as space, self as weight, perfecting the self, and the social self. These four main metaphors represented discourse strategies, both to create a collective pro-ana identity and to enact an individual identity as pro-ana. In this article, I discuss the implications of these findings for the treatment of eating disorders.
Chapter
https://www.elsevier.com/books/practical-guide-to-obesity-medicine/weaver/978-0-323-48559-3
Article
Aims and objectives: To report the findings from a unique analysis of naturally occurring data regarding self-harm behaviour generated through the global social media site, Twitter. Background: Self-harm behaviours are of global concern for health and social care practice. However, little is known about the experiences of those who harm and the attitudes of the general public towards such behaviours. A deeper, richer and more organic understanding of this is vital to informing global approaches to supporting individuals through treatment and recovery. Design: Exploratory, qualitative design. Methods: Three hundred and sixty two Twitter messages were subject to inductive thematic analysis. Results: Five themes were identified: 1) celebrity influence, 2) self-harm is not a joke (with sub-themes of you wouldn't laugh if you loved me and you think it's funny, I think it's cruel), 3) support for and from others, 4) eating disorders and self-harm and 5) videos and personal stories. Conclusions: The findings indicate that self-harm behaviour continues to be largely misunderstood by the general public and is often the source of ridicule which may contribute to delays in accessing treatment. Whilst Twitter may also provide a source of valuable support for those who self-harm, the sense of community, relatedness and understanding generated by such support may contribute to normalising self-harm and perpetuating the behaviours. Relevance to clinical practice: Our understanding of the complexity of, aetiology and most effective treatment options for self-harm behaviours are still unclear. The findings demonstrate that there is a critical opportunity to conduct further qualitative research to better understand self-harm and to utilise this valuable and internationally relevant data to support the development of effective public education campaigns and personally tailored treatment options. This article is protected by copyright. All rights reserved.
Article
A questionnaire and in-depth interviews with 20 allied health clinicians generated data on key aspects of family-based treatment for adolescent anorexia nervosa that enhance recovery, processes that engage parents in treatment, and how and why clinicians modify or adapt the manualized Maudsley Family Based Treatment model. Findings indicate that clinicians support key principles in the Maudsley model, but that the approach is not implemented in the full, manualized form. Rather, aspects are integrated with clinicians’ own clinical judgements based on assessment of the needs and capacities of families, cultural appropriateness, impact on family dynamics, and gains during early treatment.
Article
Unlabelled: During the last decade, much concern has been expressed about online pro-eating disorder communities (e.g., pro-anorexia websites and blogs) which encourage their users to engage in disordered eating behavior. The aim of the current paper is to reemphasize the importance of pro-eating disorder communities in light of the recent changes in the media landscape. With the increase of social networking sites, pro-anorexia messages have transplanted to more volatile and constantly changing media, such as Snapchat, Twitter, Facebook, Instagram, Pinterest, and many others. Most parents, educators, and health professionals are unaware of the sheer scope and nature of such pro-anorexia messages in these new contexts. The current paper will provide a review of pro-eating disorder websites, overview the effects of such websites on young people's health, examine the emergence of these messages on social media platforms, and highlight a number of guidelines for clinicians and parents. Conclusion: The dissemination of online pro-eating disorder content to different types of social networking sites is becoming an urgent issue. What is known: • Existing research on pro-eating disorder websites examines the prevalence and the content of these websites, and the effects of pro-eating disorder content on both clinical (eating disordered individuals) and non-clinical samples (non-eating disordered individuals). • The scope and nature of such anorexia messages is unknown to most adults, and many people (including parents and medical professionals) are insufficiently aware of the ease with which young people access, navigate, and use a wide range of online platforms. What is new: • Pro-anorexia messages are no longer limited to websites that can be easily monitored, but instead have been transplanted to more volatile and constantly changing media such as Snapchat, Twitter, Facebook, Pinterest, and Tumblr which makes pro-eating disorder content much more easily accessible. • This paper wants to emphasize the implications of the presence of pro-eating disorder content on websites and social media. A number of guidelines for parents and clinicians are provided.