ES[S]PRIT � an Internet-based programme for the prevention and earlyintervention of eating disorders in college students

Stephanie Bauera*, Markus Moessnera, Markus Wolfa, Severin Haugb andHans Kordya

aCenter for Psychotherapy Research, University Hospital Heidelberg, Germany; bInstitute forEpidemiology and Social Medicine, University Greifswald, Germany

(Received 4 July 2007; final version received 14 August 2007)

New communication technologies offer novel possibilities for the prevention ofmental illness, in which geographical and psychosocial distances often hamperhelp-seeking. This paper introduces ES[S]PRIT, an Internet-based eating dis-orders (ED) prevention programme for university students. The programmefollows a stepped-care approach combining various support components ofincreasing intensity. These components comprise psychoeducation, symptommonitoring, supportive feedback, peer support, and professional online counsel-ling. Participants who develop substantial ED symptoms during their participa-tion are referred to the University Student Counselling Center. We outline theunderlying concepts and various components of the programme and report firstexperiences with the approach in a sample of German college students. Finally,potentials of the approach are highlighted and the need for further research isstressed.

Keywords: Internet; eating disorders; prevention; stepped-care; college students

Introduction

College entry is considered an important transitional phase that is often experienced

as a stressful period causing psychological distress in students (Dyson & Renk, 2006;

Rosenthal & Schreiner, 2000; Soeder, Bastine, & Holm-Hadulla, 2001). Not

surprisingly, elevated prevalence rates of psychiatric disorders have been found in

college student samples (Dyrbye, Thomas, & Shanafelt, 2006; Seliger & Brahler,

2007). Consequently, adolescents who are at risk of the development of a mental

illness might need special support during this difficult phase of leaving home and

entering college to prevent onset of such disorders. However, development of targeted

prevention programmes for this population is still in its infancy.

In particular, symptoms of disordered eating as well as full-syndrome eating

disorders (ED) display common and serious health problems among college-age

women. Thus, many prevention programmes have been developed in the field of ED.

Searching for risk factors, several studies have proven excessive weight and shape

concerns to be associated with the onset of both subclinical and clinical level EDs in

young women (e.g. Stice, 2002). Consequently, ED prevention programmes have

*Corresponding author. Email: stephanie.bauer@med.uni-heidelberg.de

British Journal of Guidance & Counselling,

Vol. 37, No. 3, August 2009, 327�336

ISSN 0306-9885 print/ISSN 1469-3534 online

# 2009 Taylor & Francis

DOI: 10.1080/03069880902957049

http://www.informaworld.com

focused on the reduction of such overconcern with weight and shape aiming at a

reduction of the incidence of ED (e.g. Stice & Shaw, 2004).

While the majority of the first generation ED prevention programmes failed to

achieve changes in critical attitudes and behaviours, Internet-based approaches have

produced more promising findings. A recent study shows that the programme

‘Student Bodies’, an eight-week, Internet-based cognitive-behavioural intervention,

caused a substantial reduction in weight and shape concerns in college-age women at

risk for the development of an ED. The study also provided first evidence for the

potential of the programme in the prevention of ED onset in two subgroups of

participants (Taylor et al., 2006).

Over the past years, Internet-based programmes have become widely used in the

treatment and prevention of mental disorders (Carlbring & Andersson, 2006; Myers,

Swan-Kremeier, Wonderlich, Lancaster, & Mitchell, 2004; Patten, 2003; Pull, 2006).

They have the advantage of being accessible from everywhere and at any time,

providing support for participants for whom access to traditional care might be

difficult due to time constraints or other barriers. Many individuals suffering from

mental disorders seek help late, which increases risk for a chronic course of illness.

Technology-enhanced programmes may offer acceptable support to such individuals

in an early phase of their illness, thus allowing for early interventions on a low

intensity level. Additionally, such programmes may help to decrease barriers to

seeking traditional psychotherapeutic treatment if necessary.

Moreover, Internet technology enables clinicians and researchers to monitor

psychological impairment and symptoms in large participant samples at reasonable

time and cost which allows them to provide timely interventions if necessary. Taking

advantage of these options, we developed and piloted a targeted prevention and early

intervention programme (‘ES[S]PRIT’) for college students who are at risk of the

development of an ED.

The intervention strategy of ES[S]PRIT

In contrast to existing prevention programmes, ES[S]PRIT uses a stepped-care

approach by combining several support components of various intensity. Addition-

ally, the programme follows an individualised strategy by matching intensity of

support to participants’ needs. The underlying assumption holds that the participants’

symptoms develop heterogeneously during their participation in the programme:

while the majority of participants will not develop severe ED symptoms during their

participation, others may experience periods in which they need more intense online

support and yet others will need face-to-face counselling and potentially even more

intense psychotherapeutic treatment.

Consequently, ES[S]PRIT monitors relevant factors continuously throughout the

participation in the programme so that users can receive additional interventions in

phases when they need them. This flexible procedure is in contrast to most other

prevention programmes that provide a fixed amount and frequency of support to all

participants (e.g. by offering a fixed number of sessions that are supposed to be

completed one after the other in weekly sequence).

328 S. Bauer et al.

The components of ES[S]PRIT

When individuals first enter the ES[S]PRIT website they are invited to complete a

short online screening questionnaire consisting of the Weight Concerns Scale (WCS;

Killen et al., 1994) and the Short Evaluation of Eating Disorders (SEED; Bauer,

Winn, Schmidt, & Kordy, 2005). After entering their data, they receive an automatic

feedback according to the results. The screening aims at identifying individuals who

are either at risk of developing an ED or who already show mild ED symptoms. If

screened as at risk, individuals are invited to participate in the ES[S]PRIT

programme. Individuals who either do not display any risk of the development of

an ED or report severe ED symptoms and/or undergo current treatment for an ED

are not invited for participation. The complete inclusion and exclusion criteria are

displayed in Figure 1.Individuals eligible for participation are invited to register to the programme by

entering their e-mail address and a username and password. However, all individuals

(independent of whether they participate as registered users or not) can access the

comprehensive information material on the ES[S]PRIT website. This material

includes information on the various forms of ED, their precursors, early signals

of ED and self-help strategies. These contents were provided with support of the

German Federal Centre for Health Education (BZgA, 2007). All registered

participants also have access to the moderated ES[S]PRIT Internet forums where

they can exchange information, and discuss whichever topics they want. Participants

may use the forum to support each other, share experiences and give each other

advice. The contents of the forums are checked by a member of the ES[S]PRIT team

for appropriateness of messages every day. Inappropriate postings, such as messages

including pro-anorectic contents are deleted.

Users who register themselves for participation in ES[S]PRIT automatically enter

the supportive monitoring and feedback programme. Assuming that the participants’

well-being and symptoms change in different ways and at varying speed over time,

ED treatment ?(N=357)

Exclusion(n=29)

yes no

Too severe Symptoms ?(BMI < 17,5; daily vomiting and/ or bingeing)

yes

Exclusion(n=65) WCS ?

> 6040-60< 40

Inclusion(n=79)

Key-Items ?Bingeing; Vomiting; BMI < 18,5

yes

Inclusion(n=22)

Inclusion(only message board)(n=82)

no

no

Inclusion(n=80)

Figure 1. Inclusion and exclusion criteria and flow of participants.

British Journal of Guidance & Counselling 329

the continuous monitoring of relevant factors and behaviours is of high importance

in ES[S]PRIT. Thus, beginning immediately after their registration, participants

receive a weekly reminder via e-mail asking them to complete an online monitoring

questionnaire. This questionnaire includes the SEED (Bauer et al., 2005) and eight

questions assessing the following four dimensions: body dissatisfaction (e.g. ‘How

satisfied have you felt in your body over the past seven days?’ 1�very satisfied;

4�very dissatisfied), overconcern with weight and shape (e.g. ‘Has your eating

behaviour/your weight/your shape had a negative impact on your quality of life over

the past seven days?’ 1�definitely no; 4�definitely yes), unbalanced nutrition and

dieting (e.g. ‘On how many days over the past week have you eaten in a balanced

way?’ 1�every day; 4�never), as well as binge eating and compensatory behaviours

(e.g. ‘On how many days over the past week have you used one or several of

the following means due to a fear of gaining weight: laxatives, vomiting, excessive

exercising?’ 1�never; 4�daily). Monitoring data assessment and feedback are

managed by the software ‘Web-Akquasi’ which was developed for the purpose of

outcome monitoring (Percevic, Lambert, & Kordy, 2004).The main purpose of the monitoring programme is to track participants’

impairment throughout their participation in ES[S]PRIT. It allows for an early

identification of deteriorations and critical periods. Additionally, all participants

receive immediate automatic feedback via e-mail according to their answers of the

monitoring questions. For this purpose, a comprehensive pool of feedback messages

was formulated and integrated into the monitoring programme. The feedback follows

the rationale that had been developed within an intervention using text messaging in

the aftercare treatment of bulimia nervosa (Bauer, Percevic, Okon, Meermann, &

Kordy, 2003). Each of the four above-mentioned dimensions is divided into a

functional and a dysfunctional range. From week to week, a participant can in each

dimension change in four different ways: improve (from the dysfunctional range to

the functional range), deteriorate (from the functional to the dysfunctional range),

stay in the functional range or stay in the dysfunctional range. Each time a

participant completes the monitoring questionnaire, the programme automatically

determines the pattern of change out of these 256 possibilities (4�4�4�4). Then,

one feedback text is selected by chance out of the pool of 10 to 15 pre-formulated

statements for this specific type. Sixteen additional feedback categories were createdfor the first assessment when no comparison to earlier assessments is possible, which

results in a total of 272 different feedback categories. The feedback messages were

formulated according to the following principles: first, the messages provide social

support to participants by signalling interest in their well-being and expressing

concern in case of deteriorations. Second, they give advice on how participants can

counteract negative developments in their eating behaviour and their attitudes

towards weight and shape. In Table 1 some examples of feedback messages are given

for different patterns of change.

In case a participant reports severe deterioration (according to pre-defined

criteria) in the monitoring, an e-mail is sent automatically to the online counsellor

(see below) who in turn would contact the participant via e-mail. All registered users

are also invited to participate in online counselling sessions via Internet chat. Chat

technology is used in two different ways: 1) on a monthly basis, users can participate

in group chat sessions which are guided by a clinician, where participants can ask

general questions concerning ED, treatment options, etc., or share experiences withother participants; 2) additionally, users can register for individual chat sessions to

330 S. Bauer et al.

meet with a clinician on an individual basis to discuss more private questions that

they might not feel comfortable asking in the group setting. To do so, participants

browse an online reservation tool and register for a 30-minute chat session. The

online counsellor automatically receives an e-mail with the date of the chat session

and the username of the participant. Prior to the chat session the counsellor will then

log on to the monitoring software Web-Akquasi and check all information available

for this participant (e.g. course of impairment in the monitoring questionnaires). As

mentioned above, the online counsellor will automatically get an e-mail in the case

that a user reports severe impairment in the weekly monitoring questions. He would

then contact this participant via e-mail inviting her or him for an individual chat

session to clarify whether more intense support is needed. In general, the aim of the

online counselling is to provide support to participants and to give them advice on

what they could do to feel better. However, if the online counsellor realises that

online support is not intense enough, students are referred to face-to-face support

at the Student Counselling Center at the University of Heidelberg. If face-to-face

counselling is not sufficient, the counsellor will discuss with the participant the

options of outpatient or, if necessary, inpatient psychotherapeutic treatment.

In summary, the support tools offered within ES[S]PRIT range from online self-

help via psychoeducation, peer support in the forums and automatised feedback in

the monitoring programme, to group support in guided chat sessions, up to

individual counselling in chat sessions, and, if deemed necessary, referral to the

University Counselling Center for face-to-face counselling.

Table 1. Exemplified feedback messages of the supportive monitoring and feedback

programme for different self-reported symptom combinations.

BD OWS UND BC Feedback message

n n f d Maintain your well-balanced diet and pay attention that the

binge eating episodes or compensatory measures (i.e.,

self-induced vomiting, excessive exercise, taking laxatives, etc.)

do not become a habit. They are harmful to your body and will

not make you feel any more satisfied with your shape.

n f n f Please pay attention to your well-balanced diet. There are

better ways to improve your satisfaction with your own body/

shape than diets!

n n f f It is completely normal to go through phases in which you do

not feel so good about your body. This feeling will pass. Your

diet is well balanced and you therefore have no reason to be

unsatisfied with your body.

n n n d The last weeks give reason for worry. Please try to refrain from

using detrimental compensatory measures (e.g., self-induced

vomiting, excessive exercise, etc.) in order to avoid that last

week’s pattern become firmly established. With a well-balanced

and healthy diet, you will feel better with your body over the

long run.

Note: BD�body dissatisfaction; OWS�overconcern with weight and shape; UND�unbalancednutrition and dieting; BC�binge eating and compensatory behaviours; i�improvement; f�unchangedfunctional status; d�deterioration; n�unchanged dysfunctional status.

British Journal of Guidance & Counselling 331

Inclusion and exclusion criteria

Depending on the initial screening, participants receive a feedback message and are

allocated to a specific user group. A specific feedback message was designed for each

endpoint of the decision tree (see Figure 1). Participants who are excluded are not

directed to the registration area. ES[S]PRIT was conceptualised as a prevention and

early intervention programme for college students who have an increased risk of the

development of an ED. Due to this fact, individuals who already undergo treat-

ment for ED and individuals with substantial ED symptoms are not invited for

participation in the programme. Individuals who do not display any risk � neither in

their WCS nor in their SEED scores � are allowed to register for the message board

but cannot use further ES[S]PRIT functionality.

Preliminary findings

ES[S]PRIT was announced for the first time in an online university newsletter at the

end of January 2007. The first participant registered on 25 January. In early

February, ES[S]PRIT was announced in a regional newspaper and in the last week of

February, posters were placed in students’ cafeterias, offices and bill-boards in

Heidelberg.

By the end of April 2007, 357 persons filled in the screening questionnaire. One

hundred and sixty-six (47%) of these were students, 124 (35%) were enrolled at

Heidelberg University; 279 (78%) of the screenings were filled in by females. The

mean age was 27.4 years (SD�11.1, Median�24), and the mean Body Mass Index

(BMI) amounted to 23.0 (SD�5.45). Twenty-nine individuals (8%) underwent

treatment for an ED. The mean SEED AN Total Severity Index (AN TSI) was 0.83

(SD�0.52, Median�0.75), and the mean SEED BN Total Severity Index (BN TSI)

was M�0.78 (SD�0.77, Median�0.5). Thus, the SEED scores of the sample were

higher than those of a non-clinical sample, and lower as compared to a clinical

sample (see Bauer et al., 2005). Table 2 gives a summary of the results of the screening

procedure.According to the criteria mentioned above, 181 individuals (51%) were invited to

register for full access to the programme. Twenty-nine individuals were excluded

because they already underwent an ED treatment. Another 65 individuals scored too

high according to the ED symptom screening procedure. Therefore a total of 94

individuals (26%) were excluded from the programme due to too severe ED

problems. Eighty-two (23%) displayed no risk and were offered only access to the

message board. We further compared the SEED scores of the individuals invited for

participation with those who were not invited due to too severe impairment. The

results indicate that the screening procedure and participation rules were appropriate

for an ED prevention programme. Individuals excluded (N�94) had a mean AN TSI

of 1.21 (SD�0.63, Median�0.75) which equals the impairment found in clinical

samples. The mean BN TSI of the excluded subgroup was 1.39 (SD�0.88, Median�1.25) which scores between clinical (mean BN TSI�2.14) and non-clinical samples

(mean BN TSI�0.2). Individuals who were allowed to register (N�263) showed

substantially less impairment. Their mean BN TSI was 0.57 (SD�0.59, Median�0.5) and their mean AN TSI was 0.69 (SD�0.39, Median�0.75).

Forty-four individuals (12%) finally registered for the programme and received an

account for the personal area. The mean age of this group was 31.0 years (SD�12.7)

332 S. Bauer et al.

and they had a BMI of M�25.1 (SD�6.3). One participant’s access was limited to

the message board area because he was in the no-risk group. Participants with full

access filled in the monitoring questionnaire 163 times (M�3.8, SD�3.6, range�1�13) which is 83% of the scheduled monitoring questionnaires given on average 3.6

weeks of participation (SD�3.9, range�1�13). Seven participants ended participa-

tion after on average 6.9 weeks (SD�1.4).

Conclusions

College entry is considered to be one of the major life events for young people, often

associated with serious mental problems. In addition to psychological distress, such

problems may also negatively impact students’ achievements. For example, Hysen-

begasi, Hass, and Rowland (2005) report a strong influence of psychological

impairment on the academic productivity of university students. Both reasons

underscore the need for targeted and indicative preventive initiatives in college

student populations.

Over the past years, an increasing number of technology-enhanced prevention

programmes has been developed. Despite some promising recent findings (Taylor

et al., 2006), a systematic review found no overall effects of Internet-based prevention

programmes on ED symptoms (Newton & Ciliska, 2006). The authors state a need

for further refining the strategies applied in online prevention programmes for ED.

The stepped-care approach of ES[S]PRIT might be a first step in this direction. The

continuous monitoring of critical attitudes and behaviours allows clinicians to track

participants’ impairment in weekly intervals. The system automatically alerts the

online counsellor in case of critical developments, allowing for early interventions in

case of severe impairment. The supportive monitoring and feedback programme and

the participants’ ability to use the various support components flexibly according

to their needs display the biggest innovation of ES[S]PRIT as opposed to other

prevention programmes which often follow manualised approaches and mostly

require that all participants use the same amount and intensity of support.

Especially in the field of prevention, this traditional strategy seems questionable.

The majority of participants will not develop an ED despite their increased risk, and

thus might not need an intense intervention. As long as research fails to reliably

predict the heterogeneous courses of symptoms � i.e., ultimately who will develop an

ED and who will not � it might be better to follow a population-based stepped-care

approach, providing low-intensity support for a large number of individuals, allowing

them to access more intense care as soon as they need it. ES[S]PRIT is the first

prevention programme aiming at such a match between participants’ needs and the

type and intensity of support while reaching out for a large number of individuals.

Table 2. Results of the screening (N�357).

Severe symptoms ED treatment WCS

Binges Vomiting

BMI

B17.5

No risk

(B40)

Low risk

(40�60)

High risk

(�60)

59 (17%) 38 (11%) 23 (6%) 29 (8%) 116 (33%) 91 (26%) 150 (42%)

Note: WCS�Weight Concerns Scale; BMI�Body Mass Index.

British Journal of Guidance & Counselling 333

The results of the pilot study indicate that there is a clear need for preventive

action in the student population. Within a few weeks, more than 350 individuals

showed interest in the programme and completed the screening questionnaire. Most

of them displayed either a risk of the development of an ED or reported substantial

impairment. The screening algorithms proved valid with regard to the extent of

impairment in different subgroups.

Twenty-six percent of all individuals who underwent the screening were excluded

from the programme either due to too high ED symptom self-reports, or because

they were already in treatment. This number demonstrates the need for online

support for individuals struggling with ED symptoms. So far, ES[S]PRIT offers only

information material and addresses where these people might seek help. Moreover,

in the context of ED, often the adverse effects of the Internet, such as Pro Ana

websites, have been highlighted (e.g. Norris, Boydell, Pinhas, & Katzman, 2006). It is

important to counteract these developments by offering broad platforms to

disseminate healthy attitudes and social support.

The pilot phase shows that ES[S]PRIT is technically feasible. Given that most

parts of the programme are automated, it is possible to use it in large samples at

reasonable time and cost. However, in our view it is of high importance to connect

such offers to the traditional counselling and health care system. ES[S]PRIT is

offered by the Student Counselling Center of the University of Heidelberg and thus

extends the reach of this institution. It is known that individuals with ED-related

problems often seek help (face-to-face) very late. We assume that programmes such

as ES[S]PRIT might help to get individuals into more intense programmes (face-

to-face counselling or psychotherapeutic treatment if necessary) earlier.

At this early stage, many questions remain to be addressed by future research.

First, the acceptance of the various components needs to be studied. For example, it

is unclear why a substantial proportion of individuals who displayed a risk of an ED

and who were invited to participate in the programme decided not to do so. However,

the participants so far completed 83% of the scheduled monitoring questionnaires.

This finding indicates that individuals who register for the programme have a good

compliance concerning the monitoring component. In future studies we will

systematically study attrition from the programme and if necessary aim at developing

additional components to increase the potential to keep individuals in the

programme. Indicators for modifications of the programme will be available from

the evaluation questionnaires that participants will be asked to complete after three

months of participation as well as at their programme termination.

In the longer term, it is necessary to systematically evaluate the effectiveness of

ES[S]PRIT in a controlled study. Additionally, it will be relevant to investigate the

differential effectiveness of the various support components as well as the impact of

ES[S]PRIT on participants’ help-seeking behaviour, i.e. for example whether

ES[S]PRIT helps to provide early face-to-face interventions for participants who

develop substantial ED impairment during their participation.

Notes on contributors

Stephanie Bauer, PhD, Dipl-Psych is postdoctoral research fellow at the Center forPsychotherapy Research at the University Hospital Heidelberg, Germany. She has been

334 S. Bauer et al.

involved in the development, implementation and evaluation of several technology-enhancedapproaches for the promotion of mental health and the prevention of mental illness, especiallyin the field of eating disorders.

Markus Moessner, Dipl-Psych is research fellow at the Center for Psychotherapy Research atthe University Hospital Heidelberg, Germany. His area of research is the development andscientific evaluation of internet-delivered programs providing psychosocial support, especiallyin the fields of prevention and aftercare.

Markus Wolf, Dipl-Psych is research fellow at the Center for Psychotherapy Research at theUniversity Hospital Heidelberg, Germany. His areas of research are the development andevaluation of internet based applications in mental health and computer mediated communication.

Severin Haug, PhD, Dipl-Psych, is postdoctoral research fellow at the Institute ofEpidemiology and Social Medicine at the University of Greifswald, Germany. His area ofresearch is the development and scientific evaluation of preventive measures to decreasecommon diseases and their respective risk factors, particularly by the usage of newcommunication technology.

Hans Kordy, PhD, Dipl-Math is the Director of the Center for Psychotherapy Research at theUniversity Hospital Heidelberg, Germany. He has initiated and coordinated several large-scaleprojects in the fields of outcome and service research, eating disorders research, and e-mentalhealth research on national and European level.

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