A Personal Perspective of Online Therapy
It was December 2019, two years following my discharge from eating disorder (ED) services. My anorexia had reared its ugly head again, I was no longer fit for work, and I’d been signed off. Having previously experienced rejection from ED services three years prior due to ‘not fitting criteria’ (#dumpthescales), I had little hope of a re-referral. Still, I agreed with my GP that I wasn’t sure how I would move forward without specialist input again.
In February 2020, I experienced my third ED assessment. I was surprised (with a side helping of apprehension) to be offered outpatient treatment, although I knew I would be on the waiting list for a few weeks, if not months, before I could be seen. I commenced a very gradual return to work and waited to hear when I’d be stepping back into therapy-assisted eating disorder recovery.
Shortly after my acceptance into ED services, the world stopped as lockdown ensued. Working in the NHS, I was very aware that no one knew what was ahead, numerous clinics were cancelled, and my treatment would likely be delayed further.
In May 2020, I was contacted by ED services with an update and a ‘check-in’, at which point I was told that I would soon be commencing remote appointments. The whole concept felt quite alien, and I wasn’t sure how it could work. I did feel lucky that I’d met my therapist face-to-face at my assessment earlier in the year, so I wasn’t in the position of trying to create a connection across the screen, but there was one big sticking point: scales.
Living alone and having previously been an obsessive weigher, I’d decided not to have scales in my house as I was wary of falling back into old behaviours. A caveat of remote appointments is that I would need to weigh myself during my session each week, which would mean contradicting the protective choice I’d made. After considerable discussion, it was agreed that I would have scales sent to me, which would live double-wrapped and hidden in my wardrobe at all times outside of my appointments. Of course, I could have gotten them out at any point, but having them hidden away and an accountability agreement set, I could stick to only getting them out at the appropriate times.
As I was back working full-time, I knew I’d need to take leave or makeup hours to be able to attend my appointments. A bonus of being remote was that I didn’t have to account for travel time to get to and from ED services, as all I needed to do was log onto my laptop. This meant I could be anywhere. Often, I would be at home, in my lounge or bedroom, but occasionally I would be in a private space at work, or my parents’ house.
I was doing CBT-T, a ten-session cognitive behavioural therapy programme specifically designed for eating disorders and focuses on multiple aspects. I knew that body image was a big struggle of mine – a key element of my lapses, relapse and a sticking point in recovery – and mirror exposure was a component of CBT-T. As with the scales, I didn’t own a full-length mirror as I didn’t want to encourage unhelpful behaviours, and I didn’t really like seeing my reflection. To progress with CBT-T, owning a mirror was compulsory to use in my appointments and for ‘homework’.
Logistically, mirror exposure over a screen was challenging, trying to position the laptop in a way that meant both my therapist and I could see each other and my reflection, but it was possible. For me, mirror exposure was something that I felt may have been better conducted in a face-to-face situation; given the limitations of lockdown, it was still a helpful exercise and meant I didn’t have to make an additional leap in transferring it to a new environment. A few weeks ago, almost three years after the mirror was brought into my home, it was finally made a permanent fixture, being screwed into the wall rather than just being propped up!
Something I did find interesting, and surprising, was accessing my emotions. I know a function of my eating disorder is self-numbing. However, the reality is the discomfort and upset are just buried to come out at a later date - often in a therapy setting, when you find yourself in an environment that feels exceptionally safe, or sometimes when you’re least expecting it. I don’t remember ever getting visually upset or allowing my guard to entirely drop during face-to-face appointments, but that very much changed when I was behind a screen. Perhaps it was the added layer of ‘protection’ that enabled me to access the hurt parts of me a bit more, or maybe it was because I was in my own environment, sometimes with childhood teddies for comfort, that had lived through everything with me.
Most people will agree, recovery is not linear. Despite working through a lot and progressing in different ways, I relapsed and was signed off work again in July 2021. At that point, with support from my GP, it was decided that ED services probably wouldn’t be able to get to me quickly enough, and I wanted to avoid admission if I could. I investigated private options and was glad to find a therapist who offered in-person and online appointments. Having that flexibility was really helpful for me; I like to connect with people by being in the same room as them, but some of my most valuable sessions have been online.
Whether face-to-face or online, much of the hard work happens outside of appointment times. Getting dressed, resting, resisting unhelpful behaviours, therapy ‘homework’, and going food shopping (let alone cooking and eating) are ‘extra’ to an allocated time slot with a therapist and can be some of the most challenging processes in the recovery journey.
Acknowledging you’d benefit from specialist input is the first step; being able to access it is the second. Ultimately, I don’t think there is a ‘better’ way once these have been put in place. At a time when face-to-face appointments simply weren’t an option, I felt lucky to be in a position where I could access ED services at all.
My online CBT-T has left me with some of the most poignant steps in my recovery rollercoaster. Writing a letter to myself was one thing, but reading it aloud across the screen, then again and again, was another altogether. I still have that letter. It’s been over two and a half years since I wrote it, but the words are still true. Sometimes, if I need a reminder, I get that letter out and read it. And amongst those words is something one of my best friends said to me: the colour is coming back in your cheeks; you’re not grey anymore. Because life is so much better in colour.
This week's podcast episode explored Beanbag Health's CBT-E digital app for lifelong recovery from eating and body image issues. To listen to the podcast go to your favourite podcast app or visit here.
You can also find more information about Beanbag Health here.