Treating Eating Disorder in a Virtual Therapy

How to Make the Most of Virtual Therapy

When the pandemic led to a quarantine, clinicians and clients alike felt uncertain about how well virtual therapy would work. Since March, however, many have been able to tap into virtual therapy’s benefits, including greater access and flexibility it can offer. “People who experience eating disorders tend to seek out treatment less often than the general population,” says Grace Dowd, LCSW, a licensed psychotherapist practicing in Austin, Texas. “One of the benefits of virtual therapy is that it can break down barriers with access, insurance, and transportation.”  

Though it has brought challenges, virtual therapy has served its purposes. “I was dreading it, but it hasn’t felt tremendously different from in-person therapy,” says Heidi Dalzell, PsyD, licensed psychologist, eating disorder coach and author in PA. Some clinicians and clients find they actually prefer virtual therapy.

Getting set up for your Virtual Therapy

Because of virtual therapy’s many benefits, there’s a chance it could outlast the pandemic, perhaps as part of a hybrid approach. With six months of experience engaging in virtual therapy, several therapists share their tips for how clients can maximize its benefits.

  • Get up, get showered if you are able to, and put on comfy clothes, just as you would if you were leaving the house, recommends Melainie Rogers, MS, RDN, CDN, CEDRD-S, founder and owner of BALANCE eating disorder treatment center. Getting dressed can help get you in the mindset for doing the work of recovery.
  • At the same time, challenge perfectionistic beliefs, suggests Rebecca Leslie, PsyD, licensed psychologist in private practice in Atlanta. “The client can show up without makeup on or with sweats on and their room doesn’t have to be put together,” Leslie says, “and they’re still going to feel unconditional support from the therapist.”

  • Establish a private space and make it comfortable before settling in for the session, Leslie recommends. “If clients have a blanket or something soothing, they can keep it with them,” she says. “It might help them talk about something more challenging because they feel safer in their own home with their own things.” Leslie also recommends keeping a white noise machine next to the door so that people outside of the space won’t hear the conversation. 
  • Set up your therapy session in the same space each week if you’re able to, advises Kerry Heath, LPC-S, NCC, CEDS-S, a licensed professional counselor in Virginia and Arizona and a writer for Choosing Therapy. Being in the same space can help prepare you mentally for doing therapeutic work.
  • Prepare for the session ahead of time by journaling, suggests Gabrielle Schreyer-Hoffman, PhD, practitioner at Behr Psychology and writer for Choosing Therapy. “The more information the patient can provide about their experiences and eating disorder, the more tailored the interventions can be.”
  • Ask the therapist for what you need, recommends Dalzell. “If you need something different, don’t be afraid to bring it up if it would be helpful, even if it’s something that seems minor,” she says. Therapy provides a safe space to practice expressing these needs.
  • Pay attention to your body cues, suggests Dowd. With in-person therapy, clinicians can pick up on more of their clients’ body language. When working with someone over a video platform, therapists lose access to some of that body language. Clients can take some ownership by developing an awareness of what’s happening in their bodies and articulating that to their therapists. Dowd recommends that clients set a timer to remind themselves to conduct regular scans of their bodies so they can pick up on some of these cues.
  • Talk through the challenges of seeing yourself on camera, recommends Dalzell. Many people, particularly those impacted by eating disorders, struggle to see themselves on camera while in a virtual therapy session. Virtual therapy provides the opportunity for clients to work through that discomfort with the therapist, who can help the client increasingly tolerate seeing themselves.
  • Build in transition time to decompress after the session. With in-person therapy, you would have time when traveling home to transition from the appointment to normal life, but with virtual therapy that transition time is lost. “I encourage clients to give themselves 15 to 20 minutes after a session to decompress and process before jumping into their day-to-day roles,” says Dowd.

Making the Most of Virtual Support Groups

Support groups can be incredibly valuable in recovery. “They provide healing support, help people feel validated, and hold people accountable,” says Melainie Rogers, MS, RDN, CDN, CEDRD-S, founder and owner of BALANCE eating disorder treatment center.

For some people, the thought of participating in a support group online can be daunting. Rogers encourages anyone dealing with an eating disorder to push through that discomfort and give it a try instead of waiting until sessions take place in person. “As an act of self-care, try it, even if you’re doubtful,” Rogers says. “You’ll feel less isolated, and that’s a win.”

Kate Jarvi, MA, program manager and resident in counseling with Rock Recovery in Arlington, VA, explains that virtual support groups put more of the accountability on an individual than in-person groups. “With virtual groups, there is more opportunity to avoid attending or to attend groups without participating or focusing on the group process,” she says. “Learning to have accountability and take ownership of one’s own recovery process, however, is a huge strength that is a major predictor of success.”  

Talking about your Eating Disorder issues in a Virtual Support Group – a different experience

Rogers and Jarvi, as well as other clinicians, provide helpful tips for making the most of a virtual support group.

  • Carve out a safe, private space for the session, suggests Jarvi. That space can be the corner of a room, your car, your bathroom, or anywhere else you can feel comfortable and have privacy. “For me setting up my space involves getting a cup of tea, settling into my favorite chair or at my desk, and making sure others in the house know I need my privacy,” says Jarvi. 
  • Take time to prepare yourself mentally and emotionally. Jarvi suggests participants spend a few minutes before the group starts to journal or sit in silence. Taking that time instead of rushing into the session will help you get in the right mindset to share within a group setting.
  • Find a good set of headphones to use during the session. “Headphones help ensure privacy for everyone participating,” says Rogers. They can also help with sound quality, making it easier to be fully engaged in the conversation.
  • Take time to get comfortable with the group, recommends Sabrina Romanoff, a clinical psychologist at Lenox Hill Hospital in New York City. “Start by just listening so you can become primed to the culture and implicit rules of the group and find your footing,” she says. “Once you’ve assessed and determined the group is safe, contribute your own thoughts and ideas.”
  • Try to limit distractions, suggests Jason Shiers, a certified psychotherapist with United Kingdom Addiction Treatment Centers. “Sometimes people love to hide and keep the screen off,” Shiers says, “but I actively encourage presence and being part of the event every time.”
  • Actively engage in the group session by seeking help with managing the kids, putting phones in a separate location, and clicking out of every app and program on the computer, advises Rogers. “Show up for yourself by being fully engaged,” she recommends.
  • Share your thoughts and experiences that relate to the discussion, suggests Gabrielle Schreyer-Hoffman, PhD, practitioner at Behr Psychology and writer for  “If you relate to something a group member says or you have something that’s been particularly challenging or helpful, share it,” says Schreyer-Hoffman. “You may end up helping or relating to a fellow group member, which can help you feel less alone in the eating disorder.”

Making the Most of Virtual Meal Support

At the beginning of the pandemic, dietitians were concerned about how virtual meal support would work, but many have been pleasantly surprised by its benefits, namely that they can work through specific triggers with clients as they take place. “I can offer insight into day-to-day struggles,” says Malia Dunn, RD, CEDRD, CIEC, certified eating disorder dietitian in Boulder, CO. “Patients have actually been more forthcoming with specific challenges, and we’re able to troubleshoot those more.”

Jillian Walsh, RD, CDE, MACP, lead dietitian and therapist with change.creates.change Eating Disorder Services in Ontario says virtual meal support has also been effective during transitions points in treatment when clients might experience relapses in recovery. “We’re encouraging folks to leverage virtual meal support as a way to graduate the transition from day treatment to outpatient.”

Extract the most value out of your Virtual Meal Support

Both Dunn and Walsh share their insights into the steps clients can take to get the most out of a virtual meal support session.

  • Take note throughout the week of triggers and feelings to talk about during the session, advised Dunn. “Folks sometimes think, ‘well, the dietitian is going to lead the session,’” says Dunn, “but I find when the patient takes charge and says, ‘here are five things I really want to talk about,’ that’s when we make progress.” Before the session, spend time reading through your notes to get yourself into that recovery mindset.
  • Set up your space and gather all the food, condiments, and other supplies you need, suggests Walsh. She recommends people eat at the kitchen table if possible. “That’s a way for folks to expose themselves to that anxiety-provoking environment with support and distraction so they don’t have to go through it alone,” Walsh says.
  • Position your camera to show your entire torso and plate, recommends Walsh. “That allows the facilitator to see how you’re eating, give prompts, and coach,” she says.
  • Engage in a grounding activity for three to five minutes to mentally prepare for the experience, suggests Walsh. “Sit in a chair with a firm back with your feet planted on the ground,” Walsh says. “That helps anxiety flow into the ground and can help clients feel safer.” 
  • Engage in post-meal activities with the dietitian, Walsh suggests, especially for a particularly difficult meal. “it’s important to engage in post-meal activities to anchor yourself and stay in a recovery mindset,” says Walsh.
  • Take advantage of the virtual format to talk to clinicians when triggers happen, advises Dunn. “I can be on the phone with clients in the grocery store or maybe in the parking lot of the gym,” says Dunn. “We can work from that moment when a person is triggered instead of working from a really safe space.”
  • Advocate for what would work best for you. “There’s a shelf life when it comes to self-help work,” says Dunn. “The things the clinician says may be at the front of your mind for a day or two and they kind of fizzle out. If you’re meeting more often, you’re always cognizant and trying to break those habits.” For some people, it works well to meet for an hour a week; for others ten-minute sessions each day might be best, or perhaps two thirty-minute sessions per week. Discuss with your clinician what would work best for both of you.

by Catherine Brown, November 2020
Writer and Editor
Co-host, Eating Disorders: Navigating Recovery 
Co-editor, Hope for Recovery: Stories of Healing from Eating Disorders