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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.
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“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
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 pathologized—it 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 user’s 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, 865–875
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 friend’s
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 users’views 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 Clarke’s
(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 fit’to 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
health’early in the analytical process.
As an additional quality measure but a process not
included within Braun and Clarke’s(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 visitors’was previously described as regular and infre-
quent users. However, the revised terms ‘residents’and
‘visitors’reflected the views of individuals more accurately
because the pro-ana site was referred to as ‘home’by 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., 1–155).
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
“learned”by a website. They are horrible. Therefore, you
cannot learn how to get an ED. It just isn’t possible. It’s
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 can’t teach yourself how to be
depressed, schizophrenic or anorexic’.
Response 74: ‘An eating disorder is a mental illness. you
don’t“get”a mental illness from visiting a website’.
Response 117: ‘it’s extremely hard to “catch”an ED (I
couldn’t find a better word for “catch”) It’s not like a cold
or the flu. It’s not viral or bacterial. It’s 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 don’t“get”a 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, it’s 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 “learned”how to starve off a
few pounds and don’t 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 can’t 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 “We’re all smart people, we all know the risks that we take with our
health. That is why we don’t blame something like !!!. I don’t think
any of us blame anybody but ourselves. This place has saved my
life …Were it not for some of the advice I’ve 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.
ED’s are a mental illness that doesn’t 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. It’s easier for people to blame
sites like !!! for causing an ED rather than looking at the
underlying causes. Websites don’t 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 there’sa
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: ‘I’m going to be brutal here. I love !!!, but we
all know exactly what we are doing with this. When we
come to !!!, we know we’re choosing hell. We’re choosing
slow death. We’re choosing illness. We’re 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 don’t realise is that ED
isn’t usually about body image alone. For me, it’s
about control’.
Response 31: ‘Anorexia is not just about wanting to be thin,
it’s 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 "learned’to have ana/bulemia. I don’t
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 “learned”how to
starve off a few pounds and don’t really have EDs/lied
about having one’.
Response 19: ‘of course anorexia seems like a perfect diet, but
when they’ve 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. it’s the reason
i’m 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 can’t 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. It’s the symptom of the problem. Not the
problem itself’.
Pro-ana sites don’t 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 can’t 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
I’m 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 that’s why I chose to
be here now’.
Response 5: ‘Maybe it could bring something underlying in
themselves, out. That’s 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: ‘I’m going to be brutal here. I love !!!, but we
all know exactly what we are doing with this. When we
come to !!!, we know we’re choosing hell. We’re choosing
slow death. We’re choosing illness. We’re 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 it’s wrong and I know exactly what addic-
tion I’m getting myself in to, I come here because I want
my addiction. I don’t know that !!! can ever really GIVE
someone an eating disorder, but it can make pretty certain
that you won’t go into recovery anytime soon. We all
know, and we choose hell’.
Response 63: ‘It can trigger a pre existing disorder but it
can’t 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 you’re 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 don’t 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: ‘We’re all smart people, we all know the risks
that we take with our health. That is why we don’t blame
something like !!!. I don’t 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, it’s our choice. We can’t blame a web-
site for causing an ED’.
Response 148: ‘That’s ridiculous. BUT if it does, that’s the
person’s 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 ‘home’used 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. I’m starting recovery, too, and I still will be
here, not to “learn”to 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
“ana”take 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 I’ve gotten, I probably would be in the
hospital from a major OD on diet pills’.
Response 16: ‘I don’t 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 haven’t been through it
can’t provide’.
Response 19: ‘If it wasn’t 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.
I’ve 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 i’m 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: ‘I’m fond of this website, and not because it
“influences”me to have anorexia but b/c this is a commu-
nity that understands what i’m going through. Most of the
ppl [people] i know (I don’t mean here in this website)
just don’t get it. They think something totaly different
about what they call “beauty”and 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 author’s 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 &
O’Rourke, 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
it’s wrong and I know exactly what addiction I’m 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 (0–12 years) and
younger people (13–17 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
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