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17Web-Based Intervention for Adolescent Males with Anorexia NervosaTo m Wo o l d r i d ge , P s y. D. a n d P a u l i n e Ly t l e , P h . D.

In 1689, Richard Morton published his magnum opus, A Treatise of Consumptions, that richly described the many diseases that waste the body’s tissues. Although the London physician was recognized at the time for his detailed description of tuberculosis, Morton is known today as the first author to provide a medical account of anorexia nervosa (AN). Ironically, because the disorder is now primarily associated with women and girls, one of the two cases he described was of a 16-year-old adolescent boy. For the boy’s “nervous consumption” caused by “sadness and anxious cares,” Morton tried a handful of remedies with limited success, eventually advising his patient to retire to the country and adopt a diet of milk and fresh air (in Silverman, 1990).

Early on, the existence of male patients with AN was widely recognized. In fact, AN would have been named “anorexia hysterica” except for the existence of male patients who could not be labeled “hysterical” according to the medical custom of that time (Gull, 1874, in Silverman, 1990). Currently, epidemiological data suggest that as much as 25% of the population of people with AN is male (Hudson, Hiripi, Pope, & Kessler, 2007). Furthermore, there are reasons to think that many men with AN are overlooked during differential diagnosis (Andersen, 1990; Crisp & Burns, 1990).

Regardless, AN is now thought of as an almost exclusively female disorder. Increasingly, clinicians hear men and boys say that they are embarrassed to suffer from a “female problem” like AN. As Andersen, Cohn, and Holbrook (2000) wrote, “Few thought other men obsessively counted calories, were preoccupied with their weight, or binged and purged. Contrary to popular belief, millions of men

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face such personal struggles” (p. 26). Because males inherit an understanding of AN as a “women’s problem,” confusion and alienation accompany their efforts toward change, and their efforts to seek help are often hindered by shame and stigma.

In this chapter, we argue that the development of a web-based intervention is desperately needed for males with AN. This intervention is not intended to serve as a treatment for AN; on the contrary, it is designed both to educate and to facilitate help-seeking behavior in this population. To support the need for this form of online intervention for this population, the chapter first discusses the difficulties that individuals with AN, and males in particular, have seeking mental health and medical treatment. Secondly, print-based informational materials or bibliotherapy as well as internet-based interventions are reviewed including their clinical efficacy. Finally, guidelines for the ethical development of a web-based intervention in this population are presented, with thoughts about the future implementation and evaluation of this intervention. The goal of this chapter is to provide clinicians and academics with a model for using research and clinical skills to develop web-based interventions appropriately.

Seeking Treatment

While the majority of individuals who meet the criteria for a mental health disorder do not seek professional help (Bland, Newman, & Orn, 1997), males with AN may face additional obstacles in seeking treatment. Although the population of males with AN who fail to seek treatment is difficult to estimate, it is certainly significant. In this section, we discuss two reasons why males with AN may find it difficult to seek help.

Ambivalence in AN and Stages of Change

AN is fraught with ambivalence (Williams & Reid, 2010). Ambivalence is defined as having both positive and negative feelings, or conflicting motivations, about something. In contrast to most mental health problems, patients see anorexia as positive, at least in part (Garner & Bemis, 1982). Several studies have documented the ambivalence experienced by individuals with AN (Colton & Pistrang, 2004; Reid, Burr, Williams, & Hammersley, 2008). In many cases, patients report feeling uncertain about whether anorexia is a “friend” or an “enemy” and whether it is a problem that needs treatment (Colton & Pistrang, 2004), often spending a great deal of time weighing its advantages and disadvantages (Cockell, Geller, & Linden, 2003). Similarly, patients may experience anorexia as an empowering mark of distinction while recognizing that it causes severe damage to their health and well-being (Warin, 2004).

We have adopted the transtheoretical model of change (Prochaska, 1999) that emerged from research on how people change both on their own and with the help of therapy. According to this model, people change by progressing through a series of stages. Each stage represents a period of time

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as well as a set of tasks to be accomplished before moving to the next stage. Five stages of change are described: precontemplation, contemplation, preparation, action, and maintenance.

In the precontemplation stage, an individual is not prepared to change. In this stage, most people have little awareness of the extent of their problems, though friends and family are often concerned. In the contemplation stage, an individual is seriously thinking about beginning the change process but a commitment to action has not yet taken place. In the preparation stage, an individual develops the intention to take action toward change and may be reporting small behavior changes. In the action stage, an individual is actively engaging in change-related behaviors. Finally, in the maintenance stage, an individual is working to maintain positive outcomes and prevent relapse (Norcross, Krebs, & Prochaska, 2011). The application of this model in web-based intervention is later discussed in the “Provision of Interactive Online Activities” section.

Men’s Help-Seeking Behavior

Although many individuals with AN may struggle to seek mental and medical intervention, men face additional obstacles. There is a growing body of research that suggests that men are less likely to seek help from mental health professionals (Galdas, Cheater, & Marshall, 2005). In addition, men appear to hold more negative attitudes toward psychotherapy and mental health treatment in general than their female counterparts (Andrews, Issakidis, & Carter, 2001).

One factor consistently identified as an obstacle to help-seeking is stigma (Satcher, 1999). While seeking treatment for mental illness carries its own stigma in our society, men with AN face the additional stigma of seeking help for a “female problem” (Andersen, Cohn, & Holbrook, 2000). Moreover, research suggests that men tend to internalize the negative views of society toward those who seek professional help (Vogel, Wade, & Ascheman, 2009) and, as a result, will most likely feel acute shame and embarrassment for seeking help for a problem strongly associated with women.

There is also mounting research suggesting that adherence to traditional constructions of masculinity and beliefs regarding masculinity are significant variables influencing the help-seeking behavior of men. Studies have shown that traditional masculinity is associated with less positive attitudes toward psychological help-seeking (Berger, Wagner, & Baker, 2005) and lower willingness to seek mental health treatment (Robertson & Fitzgerald, 1992). From this point-of-view, the construction of traditional masculinity and the effort to conform to socially prescribed gender roles prevents the expression of vulnerability and need for help (Galdas et al., 2005).1

1 It is essential that we not construe men as a homogenous group to be compared against women. Indeed, multiple notions of masculinity exist among diverse populations (Galdas, Cheater, & Marshall, 2005). For example, research has shown that men in rural areas more strongly endorse traditional notions of masculinity such as self-reliance than men in urban areas (Fuller, Edwards, Proctor, & Moss, 2000). In addition, in rural areas men may be acutely aware of the lack of privacy in small towns and thus more reluctant to seek treatment because of its associated stigma (in small towns, too, the mental health expertise necessary to appropriately treat AN may be less accessible).

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Print- and Internet-Based Interventions

Although it was recognized that books exert a strong influence on the young as early as Plato’s time (374 B.C.), the term bibliotherapy wasn’t introduced until 1916. In the Atlantic Monthly, Samuel Crothers (1916) introduced the technique of prescribing books to patients seeking to understand their problems. There are many definitions of bibliotherapy but perhaps the simplest is “treatment through books” (Pardeck & Pardeck, 1988). Alternatively, bibliotherapy has been defined as “the guided reading of written materials in gaining understanding or solving problems relevant to a person’s therapeutic needs” (Riordan & Wilson, 1989, p. 506).

More recently, bibliotherapy has moved beyond the medium of print into cyberspace. Because many people do not have access to mental health services, websites have been identified as a useful tool for the provision of information about mental health conditions (Leach, Christensen, Griffiths, Jorm, & Mackinnon, 2007). According to one review, over a third of Americans report that internet use has improved the way they maintain their health (Fox, 2005). Not surprisingly, younger people are more likely to use the internet as a source of mental health information (Leach et al., 2007). In particular, adolescents tend to seek out information online, often before engaging with actual treatment. For example, one study showed that many adolescents with diabetes go online to seek information (Ravert, Hancock, & Ingersoll, 2004). The number of websites for adolescents with AN suggests the same is true in that population. Furthermore, individuals who desire to maintain their anonymity were likely to find websites a helpful source of mental health information (Leach et al., 2007). Because of the stigma associated with AN in males, preservation of anonymity may be an especially important factor.

Bibliotherapy has a substantial evidence base, with research suggesting that it is an effective adjunctive treatment for a wide range of mental health problems. In one of the earliest reviews of the research on bibliotherapy, Stevens and Pfost (1982) examined studies conducted between 1965 and 1982 and found a promising connection between bibliotherapy and attitude change (Riordan & Wilson, 1989). In a more extensive review of the literature, Schrank and Engels (1981) found considerable support for the effectiveness of bibliotherapy across a wide range of presenting problems.

Because of their relative novelty, less research has been conducted on the efficacy of internet-based interventions. Controlled internet-based studies for primary, secondary, or tertiary prevention have been reported for diabetes (van Bastelaar, Pouwer, Cujipers, Riper, & Snoek, 2011), cardiological disorders (Kuhl, Sears, & Conti, 2006), and asthma (Runge, Lecheler, Horn, Tews, & Schaefer, 2006). Internet-based interventions have been shown to be promising for the reduction of symptoms, sick days, number of medical consultations, and improving strategies for coping with illness (Fichter et al., 2012).

Even less research has been conducted on the efficacy of internet-based interventions for AN. In one study, internet-based prevention was shown to reduce the relapse rate for patients with AN (Fichter et al., 2012). For other psychiatric disorders, internet-based interventions have been shown to reduce symptoms and illness severity. In addition, internet-based interventions have resulted in a

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lower rate of relapse as well as a longer survival time until relapse (Bauer, Wolf, Haug, & Kordy, 2011). The success of these interventions suggests the utility of web-based interventions in this population.

Bibliotherapy has been widely used among clinicians (Riordan & Wilson, 1989). One survey suggested that 88.6% of psychologists and 58.8% of psychiatrists prescribe self-help books to their clients (Starker, 1986). A national survey found that 60% of psychologists prescribe self-help books “occasionally.” Only 4% of psychologists never prescribed self-help books. Of the 45% of psychologists who responded to the survey, 69% said that some patients reported being “really helped” by the books (Starker, 1988). Therapists with more experience were also more likely to prescribe self-help books (Smith & Burkhalter, 1987). Finally, written materials are the most common instructional tool used by health care professionals (Bernier, 1993). Clients frequently request written materials from their health care providers (Weinmann, 1990).

With the widespread accessibility of the internet in the 1990s, a new frontier presented itself to mental health professionals. Since that time, a wide variety of internet-supported educational and therapeutic interventions have appeared (Barak, Klein, & Proudfoot, 2009). At present, it is difficult to estimate how often these interventions are used or recommended as adjunctive treatments by mental health professionals; current trends, however, suggest that they will become increasingly popular in the future.

Ethical Issues Related to the Use of Web-Based Interventions

The Joint Task Force for the Development of Telepsychology Guidelines for Psychologists (2013) designed the Guidelines for the Practice of Telepsychology. These guidelines were developed as recommendations for ethical behaviors in the use of telepsychology defined “as the provision of psychological services using telecommunication technologies” (p. 791). Much of the discussion in the guidelines was related to the practice of direct services (e.g., therapy or psychological assessment) to clients through telecommunication technologies. However, there are parts of the guidelines that are especially relevant to the web-based intervention offered here as a prototype for clinicians.

Telecommunications include self-help websites and any information that is transmitted whether in writing, images, sounds, or other data. Communications may be synchronous, as in interactive videoconferencing, or asynchronous, as in email, online bulletin boards, or psychoeducational materials posted online. In the development of a web-based intervention, the most relevant ethical guideline included both professional and technical competence on the part of the developers, and the provision of accurate information based upon research. This would include anyone who contributes information to the website (e.g., psychologists, nutritionists, physicians). For this intervention, qualified contributors would be licensed or supervised by licensed professionals.

Psychologists are not the only professionals interested in ethical issues related to web-based interventions. In the development of health-related online sites, Bovi and the Council on Ethical and Judicial Affairs of the American Medical Association (2003) highlighted the responsibility

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of physicians to “ensure that the information is accurate, timely, reliable, and scientifically sound and includes appropriate scientific references” (p. 51). In addition, the need for following standards of “truthfulness, protections of privacy, principles of informed consent, and disclosures such as limitations inherent in the technology” (p. 51) in the provision of advice giving to online users was noted to be important.

Given the vulnerability of adolescent males with AN, it would also be vital that potential resources are provided. For example, links for locating appropriate treatment and providers, crisis or suicide hotlines, and valid and respected websites such as the National Association of Anorexia Nervosa and Associated Disorders (http://www.anad.org) should be prominently available on the website. Since privacy and anonymity while participating in a web-based intervention are important for those facing stigma such as males with AN (Kirmayer, Raikhel, & Rahimi, 2013), using such resources can help preserve these conditions.

Guidelines for Development

Because of the heterogeneity of internet-supported interventions—in terms of their therapeutic goals, intervention mechanisms, and technological sophistication—clear and consistent terminology has been elusive. In this chapter, we have adopted a classification scheme with four categories: (a) web-based interventions, (b) online counseling and therapy, (c) internet-operated therapeutic software, and (d) other online activities (Barak et al., 2009) and proposed guidelines for developing a web-based intervention. According to Barak et al. (2009), a web-based intervention is:

A primarily self-guided intervention program that is executed by means of a prescriptive online program operated through a website and used by consumers seeking health- and mental-health related assistance. The intervention itself attempts to create positive change and or improve/enhance knowledge, awareness, and understanding via the provision of sound health-related material and use of interactive web-based components. (p. 5)

Within this framework, a web-based intervention has several components: (a) program content, (b) multimedia use/choices, (c) provision of interactive online activities, and (d) provision of guidance and supportive feedback. Each of these is considered in turn.

Program Content

Program content is the central aspect of web-based intervention. In this intervention, we have divided content into two types: content designed to promote help-seeking behavior, and content

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designed to educate the reader about AN in males. In addition, it is important to also address the question of how program content is best presented.

Promotion of help-seeking behavior. To promote help-seeking behavior, the intervention must address the centrality of ambivalence in the experience of AN (Williams & Reid, 2010) as well as the specific factors that make it more difficult for men to seek help for mental health problems (Galdas et al., 2005).

When altering attitudes toward help-seeking, it is essential to acknowledge ambivalence about change (Miller & Rollnick, 2002). In fact, ambivalence is handled poorly in most treatment approaches. Typically, both parents and the medical community avoid grappling with the ambivalence inherent in the AN by focusing exclusively on weight restoration. As a result, weight is used as the primary indicator of a patient’s degree of illness and becomes the primary focus of treatment (Darcy et al., 2010). Well-intentioned comments from friends and family often focus on weight, ignoring the social and emotional dimensions of the disorder (Rich, 2006).

Research shows, however, that the identification and exploration of ambivalence is a powerful means of engaging individuals with AN in treatment programs (Pike, Loeb, & Vitousek, 1996; Treasure & Ward, 1997). With this in mind, it is essential that this intervention acknowledge that AN provides its sufferers with a profound sense of control and power while, simultaneously, wreaking havoc on health, relationships, and life satisfaction. In other words, the benefits and risks of AN must be openly acknowledged.

The factors that prevent men from seeking help must also be specifically addressed. The male experience of stigma, that has been shown to be a primary mediator of help-seeking behavior (Hammer, Vogel, & Heimerdinger-Edwards, 2013), is closely related to normativeness. Normativeness refers to the degree to which others are seen as sharing an experience or engaging in a set of behaviors (Cialdini & Trost, 1999). In this sense, normativeness can be thought of as inversely proportional to stigma and, therefore, the degree of normativeness with which an individual perceives help-seeking behavior increases the likelihood that an individual will pursue help (Nadler, 1990).

According to Mahalik (2000), there are three types of normative messages about masculinity. First, descriptive masculine norms are at work when a male observes what other males are doing in a particular situation. In this intervention, it might be particularly helpful for males with AN to hear stories about other men who have made the decision to speak with family and friends about their struggles and to seek treatment. These could be real-life stories contributed by participants or composite cases drawn from the literature.

Secondly, injunctive norms provide the cultural “shoulds” and “should nots” of masculinity. For example, men often experience the injunctive norm that they should be strong and independent (David & Brannon, 1976). Although it is possible to directly confront and argue against injunctive norms, research suggests that mental health interventions designed to decrease men’s conformity to traditional constructions of masculinity do not significantly improve men’s help-seeking behaviors (Smith et al., 2011). As a result, it is likely to be more effective to reframe help-seeking behavior so that it is consistent with injunctive norms. In the intervention, seeking help might be reframed as a sign of strength and courage, which is consistent with traditional constructions of masculinity (Good &

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Wood, 1995). Similarly, a male who conforms to the notion of masculinity as stoicism may experience seeking treatment as representing a tremendous threat to his self-esteem. In our intervention, this scenario might be reframed as a choice between taking control of AN or submitting to its demands.

Thirdly, cohesive masculine norms influence perceptions of normativeness when men observe popular and well-respected men. Men with eating disorders who have sought treatment and led productive, satisfying lives might be provided as role models for site participants in an effort to influence cohesive masculine norms. In fact, this appears to be happening increasingly in the popular media.

Educating the reader. A web-based intervention that will help males begin to understand their struggle with AN must do so in a way that accurately represents their experience. People often have limited knowledge about their problems. This is especially true when those problems receive little attention from the world around them. Educational information provides a way for people to learn about their problems in detail. In this way, it provides new facts and alternative ways of thinking about their problems (Orton, 1997).

As it turns out, existing eating disorders websites do not adequately educate their users; for example, they do not completely address diagnostic criteria and treatment options (Smith et al., 2011). One of the central tasks of these informational materials will be to provide accurate, up-to-date information about men’s struggles with AN. This will be accomplished through the collaboration of numerous clinicians with an expertise in male AN and through reference to the empirical and clinical literature.

In addition, this web-based intervention will explicitly educate participants about the change process. With the capabilities of online intervention, information and interventions can be tailored to a participant’s particular stage of change (see the following “Provision of Interactive Online Activities” section). In addition, other aspects of change will be normalized. For example, change occurs in an oscillating manner rather than in a smooth progression (Mahoney, 2003). As a result, males with AN who are struggling with change and who are beginning to initiate help-seeking behavior must be prepared to encounter setbacks and lapses in motivation. With this knowledge, these relapses are more likely to be temporary setbacks in the change process.

Content presentation. Information for online psychoeducation can be drawn extensively from literature on the design of bibliotherapy materials in order to develop guidelines for presenting written information on this web-based intervention. For this information to be effective, it must be written at a level that participants can read and understand (Griffin, McKenna, & Tooth, 2003), although the ability to read and understand may not be determined by the highest grade completed (Meade & Byrd, 1989). In fact, the average reading level of an adult in a developed country is between the fifth and eighth grade levels (Vahabi & Ferris, 1995). The Nation’s Report Card showed that among a national sample of eighth graders, 26% of the students scored below the basic reading level (National Center for Education Statistics, 2003). Discrepancies of up to five grades can exist between a person’s last grade completed and his or her ability to read and understand written materials (National Work Group on Literacy and Health, 1998).

Readers may struggle even more with written materials related to health. One study showed that the readability of the majority of health-related materials is above the mean reading ability

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of their target client groups (Cooley et al., 1995). Similarly, a study of literacy related to health terms showed that 46% of adolescent participants were reading health-related materials at below grade level (Davis et al., 2006). Because individuals who read at grade level for general prose likely read at a lower level for health-related materials, it is recommended that health-related materials be written at a fifth grade level or lower for most of the population to understand them (Estey, Musseau, & Keen, 1991).

An additional reason to emphasize participants’ reading level is that males with less education may be more drawn to a web-based intervention. More highly educated men exhibit less conformity to dominant constructions of masculinity and demonstrate significantly more favorable attitudes toward help-seeking (Hammer et al., 2013). Conversely, males with less education may have more difficulty with help-seeking and thus benefit more from a web-based intervention.

Effective written materials present content simply and clearly. They are beneficial to the reader and their information is relevant, accurate, and up to date (Bernier, 1993). Facts are presented in a balanced, objective, and focused way (Frank-Stromborg & Cohen, 1991). In particular, effective written materials should not give a false sense of hope and should provide realistic information about the presenting problem (Pardeck, 1994). One study that reviewed 58 printed materials on a wide range of health topics found that most omitted relevant information, failed to provide a balanced view of the facts, and avoided discussing uncertainties (Coulter, Entwistle, & Gilbert, 1999).

Effective format and layout plays a part in motivating a person to read written material (Griffin et al., 2003). Most importantly, content should be organized so that readers have access to key information but are not overloaded with less important material. Longer written materials may not be more informative (Vahabi & Ferris, 1995). One compelling format for presenting health information is through question and answer that allows the reader to quickly locate topics of interest. The use of subheadings has also been shown to be an effective format for presenting health information (Boyd, 1987).

Another factor of effective layout is sentence style. Sentences should be simple and succinct. One idea and a few words help readers process information and integrate it into short-term memory. Short sentences also encourage further reading (Doak, Doak, & Root, 1995). Paragraphs should be short and written in conversational style using active voice, which is more engaging to the reader (Vahabi & Ferris, 1995). Important points should be mentioned in the first paragraph. At the end of the material, a summary section should reinforce key information (Manning, 1981).

Jargon should be avoided. One or two syllable words are preferred to more complicated ones (Kitching, 1990). When technical words must be used, they should be defined in simple and straightforward language (Boyd, 1987). Active sentences written in the second person personalize the message for the reader (Bernier, 1993).

Multimedia Use/Choices

Although web-based interventions use text to disseminate program content, multimedia content including pictures, animations, audio, and video is increasingly prominent on internet sites. Although

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research on the efficacy of multimedia in terms of treatment outcome is limited, some studies suggest that participants prefer its presence (e.g., Ritterband et al., 2006). Web-based informational materials need to make use of illustrative graphics and diagrams to help explain new information.

Provision of Interactive Online Activities

Online activities allow participants to interact with the website through, for example, the use of self-assessment tools. Research suggests both that multiple interactive online activities facilitate participant interest and engagement, and that they enhance understanding of program content, making it more personalized and creating a greater sense of connectedness to the website itself (Barak et al., 2009). Equally important, online activities provide a way to measure each participant’s orientation toward change. With this knowledge, information and interventions intended to facilitate help-seeking behavior in each individual can be more accurately provided.

In the transtheoretical model of change (Norcross et al., 2011), the most frequently used measure is the University of Rhode Island Change Assessment (URICA; McConnaughy, DiClemente, Prochaska, & Velicer, 1989). URICA is a 32-item self-report questionnaire intended to assess readiness to change across a broad range of problems and yields separate scores on four continuous scales: precontemplation, contemplation, action, and maintenance.

Although measures have been developed to assess stages of change for specific eating disorders, the URICA applies to a wide range of presenting problems (and, therefore, a wide range of struggles with food and eating). As informational materials are adapted to other eating disorders, this instrument will continue to be used for stage of change assessment. In addition, URICA has been successfully applied in the field of eating disorders (e.g., Rieger et al., 2000; Treasure et al., 1999).

The first online activity in the website’s informational materials, then, will be the completion of URICA. After completing this measure, each participant will be provided with further online activities tailored to his specific stage of change. In the remainder of this section, examples of online activities developed for each of these stages are provided.

Precontemplation. In this stage, individuals do not foresee changing their behaviors in the immediate future. They can be in this stage for several reasons: they are not aware that their behaviors are problematic, they are defensive or in denial about the extent of their problems, or they are demoralized about their ability to change (Prochaska, 1999).

Although activities for participants in this stage of change should be tailored to each individual’s specific circumstances, the most essential task for individuals in the precontemplative stage is to begin to recognize the risks of their behaviors. As a group, people in this stage evaluate the benefits of their behaviors as outweighing the risks (Prochaska, 1999). Hopefully, the provision of educational information and opportunities for ref lection will encourage individuals to further evaluate the risks associated with their behaviors.

In addition, activities will begin to help boys with AN to develop a narrative that captures their experience of AN as males. Bringing order to the experience of an illness by developing a narrative consistent with one’s experience of it is an important part of healing. Kleinman (1988) began with the

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premise that witnessing and ordering the experience of illness can be therapeutic. White and Epston (1990) went further and said that the performance of our stories creates our lives and relationships:

In striving to make sense of life, persons face the task of arranging their experiences of events…across time in such a way as to arrive at a coherent account of themselves and the world around them…This account can be referred to as a story or self-narrative. The success of this storying of experience provides persons with a sense of continuity and meaning in their lives, and this is relied upon for the ordering of daily lives and for the interpretation of further experiences. (p. 10)

Stories that capture the complexity of our lives reveal the possibilities for healing that are available. Problems arise when our stories do not sufficiently represent our lived-experience such as when an inadequate narrative of AN makes recovery more difficult (Garrett, 1998). Thus, revising simplistic or limited stories is an essential component of recovery.

Contemplation. In the contemplation stage, people are intending to change their behaviors in the future, usually within the next 6 months. As a group, people in this stage evaluate the benefits of their behaviors as about equal to the risks. Although they admit the risks of their behaviors, they remain highly ambivalent (Prochaska, 1999). As such, the central task of this stage is to help individuals begin to further acknowledge the risks associated with their behaviors.

Put differently, activities should begin to help participants to identify more strongly with the part of themselves that desires change. One proposed activity draws upon the two-chair procedure from gestalt therapy (Perls, Hefferline, & Goodman, 1951). In adapting this procedure as an online activity, participants are informed that most people have ambivalence about change, and that it is beneficial to get to know their feelings, both positive and negative, about change.

The exercise has two parts. In the first, the participant is asked to speak, in the first person, as the part of himself that wishes to maintain his AN. From that point of view, the participant explains why, in as much detail as possible, he wants to maintain his AN. With this part complete, the participant adopts the perspective of the part of himself that wants to recover from AN. In the first person, he responds to the comments he made previously and elaborates his desire for recovery as much as possible. Through this activity, participants will develop greater contact with the part of themselves that desires change as well as an increased awareness of that part that obstructs it.

Action. In the action stage, people begin to actively modify their problem behaviors. To prevent relapse, it is essential the interventions are targeted toward this stage of change. For example, consciousness raising and self-reevaluation are no longer appropriate; on the contrary, action must be proactive and consistent for successful outcome (Prochaska, 1999).

At this stage, it is important that individuals begin to work directly with helping professionals, who can precisely monitor and direct change-related behaviors. In this stage, activities intended to facilitate participants’ positive attitudes toward help-seeking will be employed. Research has shown that bibliotherapy can help readers change their values and attitudes toward problems. While painful facts about life often cannot be changed, a more helpful orientation toward those facts can be developed (Hynes & Hynes-Berry, 1986). In particular, bibliotherapy can encourage people

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to recognize that they’re not alone. Others like them have faced similar problems and persevered (Pardeck & Pardeck, 1992).

In a similar way, through the use of story and educational information, activities will seek to promote a positive attitude toward help-seeking in participants. In addition, participants will be asked to actively reflect on the informational material they encounter. For example, research suggests that attempts to elicit a high degree of thoughtful consideration, or cognitive elaboration, may help to alter men’s adherence to traditional constructions of masculinity and its associated impact on help-seeking behavior (Brooks-Harris, Heesacker, & Mejia-Millan, 1996).

Maintenance. In the maintenance stage, people are working to consolidate their gains and to prevent relapse. This stage typically begins after about six months of concerted action. The duration of maintenance is highly variable; in some cases, it may last a lifetime. Regardless, to prevent relapse, people continue to apply a particular process of change, often similar to those that were employed in the action stage (Prochaska, 1999). Here, participants will be asked to maintain a list of behaviors that have helped and continue to assist them in changing. In addition, online activities provide psychoeducation about change and risk of relapse, with ongoing encouragement to continue engaging in change-related behaviors.

Provision of Guidance and Supportive Feedback

Finally, this project involves the provision of human-supported, therapeutic web-based interventions. These will utilize qualified mental health professionals to provide support, feedback, and guidance. Research strongly suggests that human-supported programs obtain larger effect-sizes than self-guided programs (Barak, Hen, Boniel-Nissim, & Shapira, 2008; Spek et al., 2006). Typically, support is offered on a one-to-one basis, immediacy of response depending on the means of communication (e.g., email, forum posting, or moderated chat rooms). The primary variables in terms of support offered are time and frequency.

In terms of time, support varies in length, ranging from a few minutes to several hours. In terms of frequency, support can range from once to several times daily to only once during an individual’s participation in the program (Barak et al., 2009). The total amount of guidance and feedback is the most frequently discussed variable in the literature. At present, it seems that more total time improves outcomes (e.g., Palmqvist, Carlbring, & Andersson, 2007). In summary, there is a strong motivation for informational materials to incorporate human-supported intervention.

Conclusion

We have strongly suggested that informational materials are desperately needed for males with AN, materials designed to facilitate help-seeking behavior in this population. We have outlined two reasons that prevent males with AN from seeking assistance: that men with AN struggle with

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feelings of ambivalence (Williams & Reid, 2010), and that they typically exhibit greater difficulty with help-seeking behavior than their female counterparts (Galdas et al., 2005). With these ideas in mind, we have suggested guidelines for the development of a web-based intervention for this population. These guidelines included suggestions for program content, incorporation of multimedia and interactive online activities, and the provision of guidance and supportive feedback by mental health professionals.

Currently, these guidelines are being implemented through the development of a web-based approach by the National Association for Males with Eating Disorders (2014). By using the transtheoretical model of change and URICA, we hope to measure the impact of our informational materials on participants. Future research needs to address the following questions: Does participation facilitate progression toward involvement with mental health providers and medical professionals? Do users move from earlier to later stages of change? How do male attitudes about seeking help for a “women’s problem” change as a result of participating in our site? From the answers to these questions, further inquiry will evolve.

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