Mobile Therapy: Using Text-Messaging to Treat Bulimia Nervosa

Cognitive-behavioural therapy (CBT) is one of the most commonly used approaches to treat bulimia nervosa, but even CBT (or any treatment) doesn’t work for everyone. Sometimes, even if CBT is helping, a weekly 50 minute therapy session is just not enough. Moreover, like with many other eating disorder treatments, dropout and relapse rates are high.

Although CBT is effective for 40–67% of patients, efforts are required to augment and improve  treatment to better serve individuals who drop out (0–33%), fail to engage (14%), or relapse (33%). The highest risk period for relapse is in the 6 months after treatment, with risk declining at 4-year follow-up. After 10 years, 11% of individuals originally diagnosed with BN continued to meet full diagnostic criteria for BN and 18.5% met criteria for eating disorder not otherwise specified.

What can be done to help the individuals that don’t benefit (or benefit fully) from CBT, or those that relapse after CBT?

Shapiro and colleagues had the idea that maybe using text-messaging (in conjunction with CBT) would increase self-monitoring and accountability of bulimia nervosa patients.

The rationale is that text-messaging might provide an immediate way of engaging with the therapist. The patients are provided feedback and support immediately, and have the knowledge (or a sense of) being held accountable for their actions (i.e., binges and purges).

It is like a daily check-in. It means you don’t have to remember or wait until your next appointment to talk about how a particular day went, or get feedback on your behaviours. You also don’t have to write lengthy diary entries, you just have to send a text.

This study was very small: a total of 25 participants (women over the age of 18 with BN who did not have major depression) were recruited, and 15 completed the study. Individuals were assessed at baseline, after the 12 week CBT program, and 12 weeks after the completion of the CBT program.

The text-messaging part was an add-on to the standard CBT treatment. The text-messaging component came in to play during the evening where participants had to text to their therapist: (1) the number of binges they had, (2) the number of purges, (3) how strong was their desire to binge, and (4) how strong was their desire to purge. Feedback messages were developed and sent according to algorithms that assessed how many goals were met and how that day compared to the previous day.

Here is an example of a text-message sent back to the patient:

‘‘Good job with resisting your strong urge to purge today. Try harder not to give into the binge eating tomorrow. Call a friend instead.’’

Out of the participants 87% adhered to sending daily nightly text-messages to their therapists. Most rated the program really well, would recommend it to a friend, and do it again if it was necessary (mostly 7 on a scale of 10). Two asked if the could continue to use the program after the study ended, because they found it helped them. 

The most important question is, however, how effective was the program in treating bulimia nervosa symptoms (for those that completed the study)?

The number of bingeing episodes went from a baseline of 6 per week to 2.5 post-treatment, and from 14.5 purges at baseline to 4.3 post-treatment. Their scores on various questionnaires assessing depression, disordered eating, and night-eating also improved.

Interestingly (but not surprisingly) Shapiro et al found a discrepancy between the number of purges that participants were reporting via text-messages and those via the binge-purge questionnaire that was based on a weekly recall of their symptoms:

…at post-treatment, the number of purges reported via text messaging was greater (7 per week) than that reported via the binge-purge questionnaire (4 per week). Thus, it is unclear which data collection method is more accurate. If the daily time stamped text-messaging technique is more accurate than retrospective weekly recall, then it is plausible that participants are significantly underreporting (either accidentally or purposefully) their symptoms when asked to report retrospectively.

It is not surprising to see that surveys and questionnaires (especially those done retrospectively) are rather unreliable. Perhaps this is a better way to collect research data for these types of things, too?

This study is a small proof-of-principle study aimed to determine whether participants would even adhere to using text-messaging to self-monitor their behaviours. Since there was no control group, it is impossible to determine whether text-messaging was better or worse (or the same) as keeping a traditional diary to self-monitor bulimic behaviours. (Though based on previous reports, more people in this study adhered to text-messaging as a way to self-monitor than the traditional pen and paper approach.)

The next step would be to do a study and compare those that use a diary and those that use daily text-messaging.

This study made me think a lot about whether or not this treatment approach would’ve been useful for me.

I did something similar with my psychiatrist for a while, though it wasn’t text-messaging, I kept a daily record, in Excel, of my binges, purges, meals, calorie intakes, work-outs, and sleeping (among some other things). It worked really well for a while (until a lot of crap things happened in quick succession and things fell apart). The worksheet was my idea, and the components that went into it were specified by me, so I was really motivated to do it and I felt the goals were appropriate.

It helped, a lot. 

I set a calorie goal (I didn’t want to eat under x amount of calories), that I wanted to go to sleep by a particular time (at that point I had a lot of problems sleeping through the night, and waking up at 2/3AM was prime bingeing/purging time), that I wanted to exercise x many times a week, and walk at least a little bit every day.

I made a list of “DO’s” and “DON’Ts”, and put it “1” for yes/do and “0” for “no/didn’t.” The “1” were green on the “DO” list and red on the “DON’T” list, and vice versa. So if I was really good and didn’t do any of the “DON’Ts” and did all the “DO’s,” my spreadsheet would be nice and green.

Sometimes I really did stop myself and thought, wait, I don’t want to see a zero there, I’ve been doing so well, I don’t want to see a “red” rectangle, I want to see a “green” one, and I’d stop myself from purging, or I’d add some extra calories to my day. It might sound silly, but I didn’t want to ruin all the green, and I didn’t want to tell my psychiatrist the next time that I really screwed up on Thursday.

It kept me accountable, and it was fast and easy.

I think text-messaging would’ve helped me too, particularly when I’d binge and purge during the day. I know that random text-messages through-out the day from my partner did help me avert potential binges (and subsequent purges). They stopped me, put me in the present, and gave me that split-second to realize I’d regret this and I have someone I can talk to. 

There have definitely been points where I wish someone would text me a few times a day to “check-in” and keep me accountable. I know that if I was in the grocery store picking binge food, and someone texted me to see how I was, there would’ve been a chance that I’d stop and leave the store without buying anything. I know this because it has happened, and it worked.

So I think text-messaging has a lot of potential, though I bet it would need to be more personalized for every individual, depending on what kind of support they need. The other question is, are there therapists willing to do this kind of thing, as it is rather demanding of their (often personal) time.

Readers, I’m interested in what you found to be helpful during recovery? What did you find worked for you to keep you accountable for your behaviours (whether it was restricting, bingeing and/or purging)?

Do you think something like this would’ve helped you or no? Have your friends, partners, or family members done something similar (or do you wish they had/would)?

PS. Fiona just pointed me to an iPhone/Android app called “Recovery Record“. Check it out–maybe it is something you can use (perhaps with your treatment team.)


Shapiro, J., Bauer, S., Andrews, E., Pisetsky, E., Bulik-Sullivan, B., Hamer, R., & Bulik, C. (2010). Mobile therapy: Use of text-messaging in the treatment of bulimia nervosa International Journal of Eating Disorders, 43 (6), 513-519 DOI: 10.1002/eat.20744

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Tetyana is the creator and manager of the blog. She has an Honours BSc in Neuroscience and an MSc in Medical Science. She can be reached at tetyana[at]scienceofeds[dot]org.


  1. More accountability has always been crucial to times that I’ve been in a better place ED-wise, along with peer support (i was in groups at the time). But really mostly the fact that I knew that I would be reporting in the next day about how I did and where symptom use was at. I think this would be helpful, but I do see a missing component of in-person support. However, as technology changes, so does therapy. I’d be willing to try this, and think it may help.

    • Hey Jessica, I completely agree that mobile therapy needs to be done in conjunction with in-person treatment. (In this study, that’s what was done: they did it alongside standard CBT treatment.)

      For me, knowing that I’d be reporting about behaviours soon, whether it was the next day, or the next week, always helped me. Always to a surprising extent, actually. I realize it helped when I wasn’t super sick, because during times when my bulimia was out-of-control, I doubt I would’ve had the ability to curb any of it. Still, when it was bad, but not *that bad*, doing my recovery worksheet, and prior to that, going to group support, really helped.

      I guess there’s something to knowing that you’ll have to own up to your behaviours, whether to your therapist or to a group of people, that helps you control the behaviours a bit better. (Which is probably why I was more likely to skip going to group when I wasn’t doing well and really should have gone.)

  2. This is really really interesting! I can actually see this being useful for me. Thank you for sharing.

  3. Thanks so much for covering this study and the tech-enhanced treatment research at UNC!

    We’ve followed up on this in recent years and are just completing data collection for a 5 year study that compared face to face group therapy for bulimia with chat group therapy moderated by a CBT therapist. No outcome data yet (we’re following people for a year after therapy is over) but It’s a novel way to deliver CBT for bulimia. The online participants also have access to a website where they can self-monitor their eating and binge/purge patterns and receive comments and feedback from their group therapists throughout the week. Here’s more information about the clinical trial:

    We’ve also developed an iPhone application called Encourage to facilitate self-monitoring but are still working out the next best steps to finalize the app and deliver it to patients and interested therapists. I think technology can really enhance therapy but there are also significant tech challenges especially regarding privacy and liability that we still have to work out as a field both in eating disorders and in medicine more broadly.

    • Very cool! Thank you for the info!

      I agree about the possibilities and the challenges. I think it is something that the field of medicine has to come around to and resolve sooner or later, because things are moving online.

      • Absolutely! I totally agree. Unfortunately, the pace of grant applications, reviews and research can’t always keep up with the fast pace of technology but we’re trying! 🙂

  4. Great article and super comment by Stephanie about the study! The privacy concerns are being worked through. Even though text messaging itself isn’t HIPAA compliant, there are great vendors out there who cover the administrative and technical components of HIPAA to ensure data privacy and security. We’ll see text messaging used in a lot more types of therapy, it’s a simple, cost effective, yet incredibly powerful medium!

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