Body and Bond in Online Care for People with Anorexia and Bulimia

Abstract

This descriptive-exploratory study aimed to understand whether and how body perception is altered in online therapeutic interventions, and the implications of this modality for the therapeutic bond, from the perspective of a healthcare team specialized in the treatment of anorexia and bulimia. The research was based on the Clinical-Qualitative Method. A total of 23 healthcare professionals participated. Data were collected through semi-structured interviews, subjected to reflective thematic analysis, and analyzed considering Linking Psychoanalysis. Three themes were developed. In theme 1, we problematize “presence” in the online environment, often sustained by voice alone, which, according to the professionals, increased the sensation of distance and refraction to the therapeutic bond. In theme 2, we highlight the effects of closed cameras as a resource that paradoxically creates an opportunity for greater patient openness. In theme 3, we explore the imaginary effect of mirroring produced by video calls. We conclude that the body is perceived differently online, with implications for the therapeutic bond, demanding caution, sensitivity, and ethics in clinical management.

Keywords:
eating disorders; telemedicine; health professionals; qualitative research; online therapy

Resumo

Este estudo descritivo-exploratório objetivou compreender se e como a percepção do corpo é alterada em intervenções terapêuticas online e quais as implicações dessa modalidade para o vínculo terapêutico, na perspectiva de uma equipe de saúde especializada no tratamento da anorexia e bulimia. A pesquisa foi fundamentada no Método Clínico-Qualitativo. Participaram 23 profissionais membros da equipe de saúde. Os dados foram coletados por meio de entrevistas semidirigidas, submetidos à análise temática reflexiva e analisados com o amparo da Psicanálise Vincular. Foram elaborados três temas. No tema 1, problematizamos a “presença” no online, muitas vezes sustentada pelo suporte da voz, o que, segundo os profissionais, incrementou a sensação de distanciamento e a refração ao vínculo terapêutico. No tema 2, destacamos os efeitos das câmeras fechadas como um recurso que, paradoxalmente, enseja a oportunidade de maior abertura para as pacientes. No tema 3, exploramos o efeito imaginário de espelhamento produzido pelas videochamadas. Concluímos que o corpo é percebido de maneira distinta no online, o que tem implicações para o vínculo terapêutico, demandando cautela, sensibilidade e ética no manejo clínico.

Palavras-chave:
transtornos alimentares; telesserviços de saúde; profissionais da saúde; pesquisa qualitativa; terapia online

The indissociability between social psychology and the sphere of individual suffering is present in Freudian writings (Fernandes, 2006). In Group Psychology and the Analysis of the Ego, Freud (1921/2011) presents the strong proposition that all individual psychology is inextricably social psychology, which we may interpret as a formulation that the processes of subjectivation are, inevitably, enmeshed in relational connections that link the psyche to the subject’s groups of social belonging. The indispensability of the other is also evident when we consider that subjectivity is constituted through presence, through early subjective exchanges that coincide with the satisfaction of the baby’s basic needs, through mirroring, through the maternal rêverie function with the child’s primary objects, and through the experience of imposed foreignness, the presence of which often carries a traumatic inscription (Roussillon, 2019).

In “On Narcissism: An Introduction,” Freud (1914/2004) posits that the baby, due to the prematurity with which it comes into the world, is precipitately inserted into bond structures and is invested in both as an end in itself and, simultaneously, as a continuous part of the group (Santos et al., 2020). Once again, the indissoluble genesis between individual and collectivity is marked, without postulating a discontinuity between the psychic and the social. As a result, the subject is constituted in its various simultaneous belongings. Freud (1914/2004) describes the experience of primordial helplessness faced by the baby immediately after birth, characterized, at the beginning of life, by primary emotional experiences mixed with physiological sensations. To cope with its state of absolute fragility, the baby requires support from the primary group of belonging in order to minimally organize its chaotic experiences. The family provides comforting experiences that, gradually, begin to give form to the instinctual drive movement, as the tension states can be, day by day, alleviated or dissipated, until the conditions are created for the baby’s basic needs to be named and symbolized (Fingermann, 2021).

Rudimentary psychic processes begin to be established, building the beginnings of what Freud (1923/2011) referred to as the nucleus of the bodily Ego, when a principle of separation between the Ego and the other emerges. The baby experiences these forms of care as a “psychic skin”, with its primordial containing function for the organization of psychic structures (Anzieu, 1988; Bick, 1967). This “other skin” assumes a vital role by maintaining a sense of bodily unity, insofar as it surrounds and contains the instinctual intensities.

Following this line of reasoning, it is possible to infer that the body is built within the primary bonds established by the baby, who is embedded in the social and cultural context into which it is born. In the contemporary digital age, the accelerated advancement of technology has contributed to the body achieving a projection that was, until recently, unimaginable (Santos et al., 2019). As a privileged locus for the exercise of social control, there is extensive production and dissemination of discourses of bodily fetishization, which preserve the characteristics of sexual morality related to guilt for the enjoyment of pleasure, associating it with sin and the need for atonement (Bocchi, 2021; Fortes et al., 2018; Santos et al., 2016).

The dissemination of this belief fuels the solitary and unrestrained race for the individual to assume the position of “self-manager” and begin to exploit themselves (Han, 2017), resorting to numerous resources (so-called entrepreneurship) in the pursuit of achieving unattainable body ideals, as if this would enable entry into the fallacious “paradise” of total well-being. Consequently, the body, heavily invested in by neoliberal technodigital capitalism, comes to be exhibited as a spectacle, reinforced by a myriad of images shared daily on social media (Sibila, 2018). It should be emphasized that the objectification of the body and the overvaluation of thinness fall more heavily on girls and women, with the body being elevated to the status of a consumable item (Bocchi, 2021; Santos et al., 2019). It is no coincidence that psychopathologies such as anorexia and bulimia nervosa are more common among young women (López-Gil et al., 2023; Dechechi et al., 2024).

Studies have shown that body dissatisfaction among adolescents is an increasingly prominent phenomenon today, and that the expectation of acquiring an “other body” through bodily modifications has been influenced and cultivated by the market that drives digital media (Di Gesto et al., 2023; Scully et al., 2023). The overexposure to social networks has increased the continuous production of discomfort with one's own body image, leading adolescents to adopt unhealthy eating habits and engage in excessive physical exercise, inappropriate use of substances for muscle definition or weight loss, as well as accessing websites and blogs that promote behaviors consistent with anorexia (Fava & Peres, 2011).

One of the most visible fields in this specific context is the suffering related to eating behavior, such as Anorexia Nervosa, Bulimia Nervosa, and Binge-Eating Disorder, among other chronic conditions whose incidence has increased significantly in recent decades (López-Gil et al., 2023; Santos & Pessa, 2022; Santos et al., 2019; Scorsolini-Comin & Santos, 2012). This increase in conditions related to eating is noticeable to those working in healthcare services, especially in adolescent health (Leonidas & Santos, 2020b). Health settings provide a more acute perspective on these issues (Scorsolini-Comin et al., 2010).

In our experience in a specialized service assisting individuals with anorexia and bulimia and their families for more than two decades, situated in a university hospital connected to the Brazilian National Health System (Sistema Único de Saúde - SUS), we have had the opportunity to closely witness suffering that has already crystallized into psychopathological organizations threatening to the continuity of life (De Stefani et al., 2023). In this specific context, diagnostic descriptions coded in the Diagnostic and Statistical Manual of Mental Disorders - DSM-5 (American Psychiatric Association [APA], 2014) are used. According to these diagnostic criteria, eating disorders (EDs) are understood as persistent disturbances in eating behavior that significantly impair the quality of life of the affected individual. Beyond merely describing and classifying the symptom cluster and its clinical presentation, our focus is on attending to the individual subject, maintaining a stance of listening to their suffering grounded in the psychoanalytic method. This is the perspective through which we will consider the subject, in light of Linking Psychoanalysis (Berenstein & Puget, 2008).

According to contemporary psychoanalytic literature (Fernandes, 2017; Leonidas & Santos, 2020c, 2023; Pereira et al., 2024), in EDs we observe a type of libidinal investment from the mother - or from anyone occupying the maternal function - that may have been excessive, failing in its task of providing the daughter with a shield against the instinctual intensities that beset the baby (Fernandes, 2006). The failure of the containing and modulating function may lead the child to become fixated in a place of undifferentiation with the figure who provides basic care in the early stages of development. This causes the child to identify with a subjective position in which they function as a narcissistic extension of the mother (Bruch, 1978; Leonidas & Santos, 2020c, 2023a).

Seen from this perspective, the unique bodily marks found in EDs express the fact that the passage from the somatic to the psychic did not occur in a satisfactory manner, leaving a trail of vulnerabilities and fissures that will cause suffering to manifest in the body in an overwhelming way, before psychic resources have matured sufficiently to modulate instinctual intensities (Fernandes, 2017). The formation of symptoms will subsequently occur as unconscious arrangements through which daughters (or sons) attempt to compensate for the deficit of para-excitation, in an effort to promote separation from the narcissistic cell in which they find themselves enclosed. It is an unsuccessful attempt to survive maternal engulfment, as the object is internalized as devouring, hungry, and insatiable (Bruch, 1978; Leonidas & Santos, 2020c, 2023; Santos et al., 2023b; Wooldridge, 2018).

In the impossibility of continuing the separation-individuation process, anorexic symptoms attempt to forge a sense of independence that denies the need for the other, which may be intensified by medical and media discourses that encourage strict control over one’s own body, appetite, and food-related impulses (Leonidas & Santos, 2020a). Increasingly, vigilance overweight and body shape has been encouraged in the name of a supposed self-management, resulting in the individual being held responsible for nonconformity to aesthetic standards or health ideals. Consequently, there is an exaggerated emphasis on maximizing individual performance (Bocchi, 2021; Santos et al., 2016, 2019).

Studies have drawn attention to the difficulties that patients with anorexia and bulimia face in establishing and maintaining relationships in general (Gil et al., 2022; Valdanha-Ornelas et al., 2021, 2023), whether in the sphere of family, romantic, marital, or friendship relationships (Leonidas & Santos, 2020a; Matta Simões et al., 2023; Santos, Sola et al., 2023; Simões & Santos, 2024; Siqueira et al., 2020), or in connection with healthcare providers and other care spaces. This may lead to the emergence of impasses in the stabilization of the therapeutic bond, an essential requirement for the care of individuals diagnosed with anorexia or bulimia (Maia et al., 2023d; Santos & Pessa, 2022; Scorsolini-Comin et al., 2014; Webb et al., 2022; Werz et al., 2022).

In the context of AN/BN, it is common to encounter severe and disconcerting symptoms whose repercussions can create barriers that hinder the therapeutic bond (Goulart & Santos, 2012; Souza & Santos, 2015; Valdanha & Santos, 2017; Webb et al., 2022; Werz et al., 2022). From the perspective of Berenstein and Puget (2008), the bond is understood as the space that exists between two subjects of the unconscious in presence (which in itself already involves corporeality) and the ties that keep them connected. Transposing this perspective to the care setting, the therapeutic bond is configured as a specific tie, marked by the therapeutic alliance (Koch, 2023; Peres, 2009). Zetzel (1956) defines the therapeutic alliance as the establishment of an emotional connection between the professional and the person receiving care, anchored in ego functions and referring to infantile object relations, which are reactivated in transference. According to the author, this alliance will function as a dynamic propeller of care, serving as a key component in the management of psychotherapeutic treatment.

Therefore, in the psychoanalytic conception, the body is not a natural given, but a phenomenon constituted and constantly transformed within a network of bonds, in the intertwining of intra-, inter-, and transsubjective spaces (Berenstein & Puget, 2008; Santos et al., 2017). The bond is rooted in the subject’s experience of their own body and in the experiences of being fed in the first contacts with the maternal breast, such that each person's body, singular-plural, inhabits and is built within the intersubjective, bond-based space, which in turn is enveloped and contained within the transsubjective space. Thinking of the body as inseparable from relational bonds is, therefore, a requirement of the context in which contemporary psychological suffering is situated, where corporeality and its avatars occupy a central place (Maia et al., 2023b; Santos et al., 2019, 2023b).

From this perspective, body and bonding are primary constructs for reflecting on psychological suffering, such as that experienced by people living with anorexia or bulimia, especially with regard to the therapeutic bond (Goulart & Santos, 2012). However, the experience of connection between body and bond was radically altered with the outbreak of the COVID-19 pandemic, which, among other effects, forced people to remain confined and to conceive of the body as a possible messenger of finitude (Birman, 2020; Okamoto et al., 2024; Oliveira-Cardoso et al., 2020, 2022a; Santos et al., 2024a, 2024b; Sola et al., 2024), which produces a series of consequences that impact subjectivation (Maia et al., 2023c; Oliveira et al., 2020b; Sola et al., 2022, 2023). The pandemic accelerated latent processes that were already underway, such as the virtualization and increasing medicalization of life, the blurring of boundaries between fantasy and reality, the explosion of social media, the massive use of Information and Communication Technologies, and the dilution of the boundary between the virtual and offline worlds (Holpert, 2021; Oliveira et al., 2021, 2020a, 2020c; Oliveira-Cardoso et al., 2021, 2022b; Susemihl, 2020).

This “brave new world” inaugurates new demands that must be problematized in the COVID-19 context, with the challenge of thinking about the body in a historical moment of its greatest dematerialization, with the intensification of the virtualization of relationships due to social distancing measures and their repercussions on bonds, which became increasingly rarefied in the scenario disrupted by the pandemic (Birman, 2020; Emidio et al., 2021, 2023; Santos, Sola et al., 2023; Sola et al., 2021, 2024). The impacts for people undergoing treatment for their AN and BN symptoms need to be considered and examined through studies that allow for a dissection of the effects on the network of bonds caused by the instability generated by the ruptures of daily life during the pandemic period (Maia et al., 2023a). Such effects must be investigated not only in terms of the adversities resulting from the health crisis, but also from the perspective of the invitation to new possibilities and opportunities for change that the moment brings, especially the challenges in maintaining the therapeutic bond, which is essential for preserving the quality of healthcare for populations in situations of greater vulnerability (Ferracioli et al., 2023; Maia et al., 2023d; Silva et al., 2024; Souza & Santos, 2015; Werz et al., 2022).

In the specialized multidisciplinary service in which we are embedded, health promotion activities were transitioned to an online format at the onset of the health crisis (Gil et al., 2023; Santos, Maia et al., 2023; Silva et al., 2024). Among the challenges imposed by this new reality, noteworthy aspects in our experience include the need to preserve welcoming spaces, ensure the availability of a quality internet connection, and secure access to technological devices for their use (Santos, Maia et al., 2023). This context led us to formulate the following research questions: “Considering that the body is constituted in bonds, how is body image transformed in the online care modality? What are the implications of these transformations for the construction of the therapeutic bond?”

In seeking to answer these questions, we designed this study with the objective of understanding whether and how body perception is altered in online therapeutic interventions and what the implications of this modality are for the therapeutic bond, from the perspective of a healthcare team specialized in the treatment of people with anorexia and bulimia.

Method

This cross-sectional, exploratory study adopted the Clinical-Qualitative Method (Turato, 2013) as its methodological framework, as it is well-suited to addressing research problems arising from clinical practice in the health field, grounded in its three epistemological pillars: existentialist, clinical, and psychoanalytic concepts. In line with this framework, the study adopted Linking Psychoanalysis (Berenstein & Puget, 2008) as its theoretical foundation, which reorients the understanding of the unconscious from its social (transsubjective) and linking (intersubjective) dimensions (Maia et al., 2023b; Santos et al., 2017).

The research was conducted in an outpatient clinic specializing in EDs located in a teaching hospital in the southeastern region of Brazil (De Stefani et al., 2023). Linked to the tertiary level of the SUS, the service is staffed by a specialized multidisciplinary team composed of psychology, nutrition, occupational therapy (OT), and medicine (with specialties in clinical nutrition and psychiatry). As a teaching hospital, the professionals present varying levels of training and institutional involvement, including staff members, residents, interns, and volunteer researchers. The outpatient clinic receives referrals from the public healthcare system, and when the research was conducted, 14 individuals from municipalities in the region aged between 17 and 69 years (mean age 31 years) were being treated. Ten patients self-identified as White and four as Black (Black or Mixed); 12 identified as cisgender women, one as a transgender woman, and one as a cisgender man.

Weekly meetings are held by the multidisciplinary team for the development and monitoring of each patient’s individual therapeutic plan (ITP), discussion of clinical approaches, and planning of the weekly care routine. Interventions are conducted individually, offered by all professional categories, and in group settings, coordinated by professionals in psychology, nutrition, and OT. As of March 2020, due to the COVID-19 pandemic, all activities were transferred to the online environment: the clinical nutrition team continued providing services only by telephone, while the other professionals adopted individual video calls and group sessions organized on digital platforms, using cameras and microphones. With the service’s coordination approval, the lead researcher was immersed in the field for eight months prior to the beginning of data collection. This immersion was carried out in accordance with the recommendation of the Clinical-Qualitative Method (Turato, 2013).

The study included 23 team members who were part of the service from March 2020 to May 2022. All eligible participants were invited, and only one professional declined. Accordingly, the purposive sample included nearly all members of the service. Regarding sociodemographic characteristics, of the total number of participants, four were cisgender men, one of whom was Black, and 19 were cisgender women, of whom only two self-identified as Black; the others self-identified as White. The Brazilian Economic Classification Criteria (ABEP) ranged from classes A, B1, B2, and C1.

Concerning academic background and area of practice, 12 participants were from the psychology team. Professional experience ranged from less than one year to 22 years in the ED field. Two participants were psychiatry residents, with a maximum of one year of professional experience in the ED field. Three were from clinical nutrition, two of whom were resident physicians with one year of experience in the field, and one was a professor with eight years of experience working with EDs. Four participants were from the nutrition team, three of whom had three to six years of experience, and one had worked in the field for 40 years. Two participants were from the OT team, one being a resident and the other a staff member, with one and eight years of professional experience in the ED field, respectively.

The instruments used were: a sociodemographic data form for participant characterization, which included information such as age, gender, profession, and length of professional experience, and a semi-structured interview guide, which included the following questions: (1) In your care of individuals with EDs, what does “being present” mean to you? Do you feel that being present online differs from being present in face-to-face interactions? (2) In your opinion, does the way individuals with EDs perceive their own bodies influence their bonds? Is this different in online care? (3) In your opinion, do patients express different concerns about how their bodies are perceived online compared to in face-to-face sessions?

The field research consisted of three stages: (1) Preparatory phase and immersion of the researcher in the field; (2) Data collection for sociodemographic profiling; (3) Administration of the semi-structured interview. The interview was conducted adopting the clinical attitude of existential understanding recommended by Turato (2013). The interviews were carried out throughout August 2022 using digital platforms and had an average duration of 30 minutes. The online format was chosen due to epidemiological constraints and in compliance with the health precautions recommended, following the COVID-19 prevention protocol adopted by health services (Fiocruz, 2021).

The recordings were made with prior consent from participants and were subsequently fully and literally transcribed by the field researchers. The transcriptions totaled 147 pages, typed in Times New Roman font, size 12, single-spaced, on A4-sized pages. To ensure confidentiality and anonymity, codes were assigned to identify each participant: Psi1, Psi2... for psychology professionals; Psiq1, Psiq2, for psychiatry; Nutri1, Nutri2... for nutrition professionals; Nutro1, Nutro2... for clinical nutrition professionals; OT1, OT2, for occupational therapists.

The research corpus was analyzed using the perspective of Reflexive Thematic Analysis (Braun, Clarke, Hayfield, & Terry, 2019), which allows for greater flexibility in dialoguing with the adopted theoretical framework. Furthermore, from an epistemological standpoint, thematic analysis is compatible with the Clinical-Qualitative Method, as it values the analysis of data from the standpoint of the meanings constructed by the study participants. As proposed by Braun et al. (2019), the analysis followed six stages: (1) exhaustive reading of the completed transcriptions; (2) initial coding of the research corpus, carried out by the researcher using the Atlas-Ti software, which enabled the identification of relevant codes to answer the research question; (3) grouping of codes into themes and subthemes, relating them to the general context of the data; (4) review of themes and verification that sufficient data supported them; (5) production of a thematic map of the data, organizing them into a consistent whole; (6) drafting of an analytical narrative, going beyond mere description of the themes, illustrated with excerpts from the participants’ reports.

In stage 1, all records in the database were coded. In this study, the codes related to the body and bond formation in the digital space were highlighted, following the proposed objective. Furthermore, to enhance the rigor of the analysis, the themes (stage 4) were discussed with an external reviewer and subsequently within the research group. Finally, as recommended by the Clinical-Qualitative Method, the final narrative (stage 5) was presented to the participants during a team meeting, providing the opportunity for feedback and revision of the study’s findings.

The study was approved by the Research Ethics Committee of the institution to which the researchers are affiliated (CAAE No. 54292821.4.0000.5407). The research procedures, from the invitation to participants, data collection, analysis, and storage, adhered strictly to the ethical guidelines outlined in Resolution No. 510/2016, which regulates research involving human subjects. The recommendations proposed by the Federal Council of Psychology - CFP (Resolution No. 016/2000) were also observed.

Results and discussion

Based on Reflexive Thematic Analysis, three thematic axes were identified.

Theme 1: Body “closed” behind the cameras: the bond and presence in the online setting.

When we asked about the role of the body in establishing bonds with patients receiving online care, one of the most recurring and frequently mentioned issues by participants was the patients’ tendency to “avoid” being seen, often refusing to turn on their cameras during video calls. A nutrition professional noted: “There are patients who turn off the camera, you know. Sometimes it’s just the voice, and then it gets even more difficult” (Nutri1). Two other participants pointed out that, beyond simply “closed cameras,” some patients were observed to “hide” from the camera: “Hiding instead of not turning it on. [...] So what happens? Sometimes she positions the phone in a way that you can’t see much” (Nutri3); “Sometimes she wanted to hide, or she would join the session, and the camera would be kind of pointing at the ceiling” (Nutri4); “With the camera, you’re not seeing everything, you know. She can hide” (Psiq1). In a qualitative study that investigated the experience of online care, Benzel and Graneist (2023) identified the loss of embodied communication as one of the challenges of the remote format.

The expression used by one participant, “it’s just the voice” (Nutri3), draws attention to the fact that, often, presence and attentiveness are ensured solely through speech. This is also evident in the need to repeatedly check during the session: “Are you there? Can you hear me?” (Nutro2), indicating that presence can be seen and heard, but not necessarily touched. These serve as online communication supports (Costa & Gomes, 2022; Stukenberg et al., 2022). The account of a psychology participant illustrates this dimension of the experience:

When we talk about eating disorders, we are talking about the body, and then when we move to the online setting, we do not see the body fully, we only see the person’s face, and sometimes not even that, we just see that little circle there [...] So, I was speaking to a voice, there was no body, it was a voice with an eating disorder... No, obviously, you know, it is a human being, but I could not see who that person was. (Psi6)

The act of not keeping the camera on was reported by several participants as a significant loss in the quality of care provided in the online modality, increasing the difficulty of establishing contact with the patients. One professional considered that this may reflect the symptoms: the feeling of exposure is heightened due to impairments in the formation of self-image, which amplifies persecutory feelings and the difficulty of dealing with one’s own body, especially with the dimensions of seeing and being seen by others (Santos et al., 2019): “Sometimes we would see that she turned on the camera and said: ‘Oh, I did not want to turn on the camera because I look horrible today, my face looks fat.’” (Psi3).

For example, this happened the other day when I was attending a young woman [...]. She interrupted the session and said, “Ah, I am going to answer the door...” The intercom rang, I think a delivery arrived, and she turned off the camera so I would not see her. I thought it was probably because she does not want me to see her body. So, you see that the person finds little ways to hide as much as possible (Nutri3).

In other reports, participants associated avoiding exposure on camera with a refractory attitude toward the treatment, that is, a posture of closing off the therapeutic bond and resisting change. Resistance to treatment have been recognized since the earliest descriptions of EDs (Bruch, 1978; Maia et al., 2023d) and may manifest openly and defiantly, through successive absences, requests to cancel sessions, and dropout, or through subtle manifestations and veiled expressions, such as attacks on the bond, symptom exacerbation, or, as observed in the online format, the “camera being turned off.” According to the interviewees, this relates to the type of recurring psychic suffering, with possible similarities between the high selectivity that patients show in their eating behavior and the non-acceptance of the provision of professional help (Goulart & Santos, 2012; Santos & Pessa, 2022).

Wooldrige (2022) argues that the movement of refusing help is the result of a symptomatic commitment formation: people with AN/BN seek, through behaviors of self-closure and aversion to closeness, to keep the other at a distance. It is a defensive strategy adopted to preserve control over situations. The rejection of accepting help and the propensity for isolation can be observed during online appointments in the refusal to turn on or keep the cameras on. These are defenses against the fear of losing control and the difficulties of maintaining intimate relationships. Proximity to the other intensifies the anguish generated by the encounter.

At times, the symptoms are experienced by patients as a second skin (Bick, 1967), a kind of armor that keeps them closed within themselves, instead of functioning as a porous membrane that allows access to (and from) the other. Therefore, the anorexic or bulimic symptom may function as a kind of prosthesis that simulates, through psychopathological means, what the primordial subject of the bond should have acquired since the early stages of development, namely, the ability to maintain a sense of bodily unity, which allows for the constitution of a bodily envelope (Anzieu, 1988; Valdanha-Ornelas et al., 2023). Accordingly, the restrictive eating pattern and the rejection of receiving help bear a certain structural similarity: they are fortifications, ways of protecting oneself from excesses and the intrusiveness of the other, refusing “dependency” and engulfment by the maternal figure (or by any other subject of the bond perceived as an intrusive presence), forging a false sense of identity and autonomy (Dechechi et al., 2024; Fava & Peres, 2011; Wooldrige, 2018, 2022).

From the psychoanalytic understanding of anorexic and bulimic symptoms, the bond that patients establish with the healthcare team can evoke experiences of discomfort because it offers the possibility to rearrange libidinal investments, redistributing psychic energy in relations with the world and with people. What patients long to achieve with the reproduction of their symptoms is precisely the opposite: to withdraw from the world, to disconnect, to enclose themselves in an impregnable fortress, a system of no entry defense (Wooldrige, 2022). One of the nutrition professionals reflected on these defenses:

Perhaps these moments when they were not present in some consultations, when they had the camera turned off, reflect this difficulty in dealing with the body, with the treatment; therefore, [...] online they showed this in other ways, such as turning off the camera (Nutri4).

We identified in this account another issue strongly marked in the interviews: the problematization of presence. Susemihl (2020, p. 62) points out that, from the perspective of psychologists, the online presence can become more “diffuse.” In our study, when commenting on participation in the online groups offered by the psychology team, some interviewees also reflected on the quality of presence of patients who kept their cameras off: “Ah, entering a group but not turning on the camera... then we do not know if they are really there or not” (Psi5); “It was uncomfortable, like [...] There were participants who joined, said nothing, and kept the camera off, so we did not know if they were there or somewhere else” (Psi12).

It is inferred from the reports that the act of “turning off the cameras” was perceived as anxiety-provoking by the professionals, as it fueled doubts regarding the real level of participation and engagement of the patients, and whether they were on or offline. Based on the Link construct coined by Puget and Berenstein (1997, 2008), we understand that being before another subject of the unconscious requires admitting the existence of a difference (perceivable, representable, elaborable), as well as the inscription of another difference, which is radical and irreducible, for which there is no psychic representation. This radical difference, which the authors call ajenidad, is what delineates the self-other separation. It is the psychic work on this structuring difference that marks the self/non-self boundary. Therefore, it is the marker that establishes presence and maintains the bond, since the structural difference is the element that keeps us united and in relation, without the risk of confusing ourselves with one another.

Based on the theoretical framework of Linking Psychoanalysis developed by Puget (2002, 2003), we can question whether there is actual presence in online care. Is it possible to coexist with differences in synchronous clinical care mediated by Information and Communication Technologies? What we observe, from the reports obtained in this study, is that even if the body is objectively seen, perceived, or felt differently (given that what is seen is the image refracted through the camera lens), the presence goes beyond that: it involves the possibility of listening, of offering attention and consideration to the other’s psychic world, and of having an internal disposition to sustain the encounter with foreignness: “Am I present there? I am! But the patient is at home. And I am here, even if I do not see much” (TO2); “Attention is there, the focus is there, the view, the voice are there. So, I think it is a presence, but I think it is different” (Psi3).

Therefore, according to the meanings attributed by the healthcare team members, the body is made present in distinct ways online; however, it still constitutes presence, provided there is a genuine disposition to “be with” and “do with” foreignness and the radical difference (Puget, 2012). From this perspective, we need to consider: could evading, hiding, or turning off the camera be merely defenses against the intrusiveness of the other? Or could these phenomena accommodate other interpretations, as singular modalities of participation that require new understandings beyond conventional meanings?

Theme 2: When the body is “hidden”, is it necessary to close the cameras in order to open up emotionally?

The participants raised the hypothesis that the transition to digital care may have been a facilitating factor for some patients: “Those who have difficulty with eye contact, or showing the body, or great difficulty with deep contact, or difficulty in looking at the other... So, I think some patients even felt more comfortable with online care than with in-person care” (Psi1). Other professionals corroborated this perception: “I think, in general, it seemed that patients felt somewhat more comfortable because we were not seeing the body. So much so that I think many patients with ED used the pandemic as a resource, let us say, to stay at home” (Psi3); “Online care allows other issues of the person’s life to emerge, not so much the body, because they do not need to be so worried about this body that will appear, since they have control over the image through the camera; and also because the person, by not leaving home due to the pandemic, does not have others looking at them” (Psi4); “Therefore, I notice that some patients feel a little more comfortable online with me, so I have had online experiences that were better than in-person for the patient” (Psiq1).

From the reports, it is possible to deduce that, from the professionals’ perspective, being kept out of the other’s field of vision may have facilitated the emotional openness of the service users. Sedlacek (2022) argues that relationships in which the other is not physically close can facilitate the activation of regressive and transferential processes, which would allow deepening contact with the other-and perhaps we can add: with the other within oneself, that is, the unconscious.

Prado et al. (2021) point out that the function performed by the clinician is not conditioned to literal physical presence, that is, to sharing the same physical environment. The unusual pandemic context imposed preventive and restrictive contact measures that acted as catalysts for change in the therapeutic setting. Professionals had to reinvent several aspects of care already established by tradition, exercising creativity and flexibility of technique (Santos et al., 2024a, 2024b; Sola et al., 2021). This redefinition of therapeutic practice was made possible by maintaining an inner frame, based on a mindset disposition that allowed being with the other and listening to them (Almeida, 2020; Costa & Gomes, 2022; Figueiredo, 2020; Stukenberg et al., 2022).

Figueiredo (2020) argues that care without image can be a facilitator for negative hallucination, that is, the artificial blindness advocated by Freud and endorsed by Bion as one of the pillars supporting floating attention, proposed through the abstention from the desire for prior understanding provided by sensory perception data. According to participants in the studies by Benzel and Graneist (2023) and Stukenberg et al. (2022), this can intensify the emotional experience. One of the psychology participants argued along these lines:

Do you know the idea of “no memory, no desire”? In this case, you really are without memory, because you do not know, so I think it facilitates moving more to the symbolic level of the conversation, because you are not seeing her body, whether she is fat or thin. You cannot even discern, even if the person asks you directly, “Do you think I have gained weight?” Unless the person has gained a lot of weight, you do not have that response to give, even if you wanted to. So I think this, to some extent, can be a facilitating factor” (Psi4).

In the discussion of care provided in the digital space, some authors (Figueiredo, 2020; Sedlacek, 2022; Stukenberg et al., 2022) argue that the absence of images can be dangerous in cases where the distinction between self/non-self is precarious or weakened, as is commonly observed in individuals diagnosed with AN/BN. The construction of the bodily Self is compromised, in what Roussillon (2019) called narcissistic sufferings.

Emotional experience, which still occurs at a basic pre-symbolic level, requires that the infant receive emotionally empathic responses from caregivers, as well as experience sustaining emotional processes that convey a sense of comfort, containment, and continuity amid the chaotic universe of primary experiences. If all proceeds well toward maturation, these experiences can be gradually organized, symbolized, and encoded in words (Fingermann, 2021), constituting para-excitation, that is, a protective dam against the invasion of pulsional motions and intense, raw sensations emanating from both the external world and the interior of the infant’s body (Fernandes, 2017).

In individuals with AN/BN, this containing bodily envelope, which enables the symbolic function to be well established, is fragile and porous (Roussillon, 2019). This is evident in the therapeutic relationship in the difficulty of translating suffering into words. For this reason, anxieties often overflow into bodily symptoms, actings, and a notable instability and precariousness of the therapeutic bond, whose fabric can easily fray and rupture (Wooldridge, 2022).

With this in mind, we can reflect on the consequences of online care for this specific population, especially when presence is sustained “by a thread,” that is, only by the look or voice and other sensory cues of the psychotherapist. The lack of imposition of such a radical difference or the blurring of the self/non-self boundaries, imposed by view and physical contact that are suppressed or significantly restricted in the digital environment, can be quite challenging, according to a participant in psychiatry: “It becomes more difficult to separate what is me and what belongs to the patient. I had nothing to support myself there, to think: ‘Is everything really okay? Or is it not?’” (Psiq2). This report suggests that doubt lingers in the clinician’s mind, an uncertainty that cannot be dispelled by immediate perception. In the absence of secure and “reliable” support to conduct a careful and grounded evaluation based on data from reality, the professional tends to take as true what patients say about their own bodies, which amplifies the sense of erasure of the boundary between self and non-self.

Perhaps not having access to the patients’ bodies may reduce this barrier somewhat and allow for a more faithful listening to their own perception of their bodies. However, at the same time, I consider the other side: where do I fit in this story? Might I not be entirely absorbed into the patient’s worldview? Where do I remain separate from this patient? [...] without access to other information, I cannot position myself outside of this perception” (Psiq2).

This concern with the loss of boundaries appears in the reports of other professionals, who feel the lack of objective data about body shape and weight, and complain about the difficulty of detecting the “clinical signs” of weight loss. They understand that, if these signs were accessible, they could be less dependent on the distorted descriptions that patients make of themselves: “Then I think it becomes difficult, because sometimes I had no idea how much the patient was emaciated. There were days when she had the camera turned to the side, so I ended up not having much sense of it; it was more based on what she told me” (Psi12); “There was also the issue of literally being able to observe, on the patient’s body, when she was improving or had worsened” (TO2); “We do not have the perception of the whole, right. So sometimes she says she was fine, that she neither lost nor gained weight, but sometimes that is not the case, you know. We cannot see” (Nutri1); “Sometimes it is necessary [...] to bring some elements of reality: ‘Look, it seems that things are not going so well, right’ [...] In face-to-face sessions, we can have a somewhat better sense of what is actually happening with these patients” (Psi2).

Other studies on online care (Costa & Gomes, 2023; Sedlacek, 2022; Stukenberg et al., 2022) also showed convergent results, highlighting that the limited access to data related to the body of the person being treated can be a complicating factor. From the perspective of Linking Psychoanalysis, we can understand the importance of establishing a therapeutic alliance based on transference (Zetzel, 1956), which can be facilitated by the “camera off” approach, but also by the analyst’s position as guarantor of the consideration of foreignness, that is, as the other in the relationship (ajenidad) who can sustain radical difference (Puget, 2003, 2012). This latter function may be hindered by the weakening of the boundaries between self and non-self, felt from the precariousness of reality data that would allow, in the professionals’ view, confronting what the person is saying or perceiving about themselves.

Considering the above, a feasible alternative would be to seek technical and theoretical support to, on the one hand, maintain a “without memory and without desire” stance, facilitated by care devoid of images and, on the other hand, present oneself as a foreigner and not remain engulfed and trapped in the relationship, avoiding repeating the problematic and even lethal situation of the primitive bond between primary caregiver and infant. Only in this way can the psychotherapist constitute themselves as a living companion (Alvarez, 2012) for patients with extreme difficulties in feeling alive. This can be a viable alternative for the clinician, promoting interventions sustained by speech that preserve the cohesive force of presence and contact with foreignness at a threshold still bearable for the patients, while actively participating in this construction (Almeida, 2020; Cardoso et al., 2022).

This stance may help maintain a therapeutic bond by, on the one hand, relieving patients from the clinician’s constant gaze, a scrutinizing look that may be experienced as devastating by individuals with AN or BN. On the other hand, it allows for the preservation of difference and presence, helping to avoid the anguish of reenacting a primary bond marked by the early loss of individual boundaries and the erasure of difference with the other (Wooldridge, 2018).

Theme 3: The screen as a mirror: the view of oneself in the care of people with EDs

The decision to turn on the camera in online care implies exposure to mirroring, as expressed by a participant: “I think this was facilitated online by the distance, by not seeing the other, but what I am saying is that there is a trade-off, which is the fact that you see yourself. You keep looking at yourself all the time, which does not happen in a face-to-face relationship” (Psi1).

It should be emphasized that we live in a society in which images are reproduced and disseminated to exhaustion, with the body possibly being the most promoted, shared, and commercialized image on virtual social networks (Holpert, 2021; Santos et al., 2019; Sibila, 2018). The overvaluation of the thin body and/or with muscles and defined shapes, a habitual consumer of supposedly healthy diet/light products, is a phenomenon that has gained momentum in recent decades, parallel to the ascending status of the body as the main identity marker, fetish object, and control mechanism, enhancing consumption in capitalist society (Dechechi et al., 2024; Santos et al., 2019).

According to participants’ reports, patients’ self-observation on the camera may activate obsessive concern with their own bodies, increasing the need to control how they are seen through the view of the other in the relationship: “Seeing oneself on camera, in cases of eating disorders, I think affects a little more because of the issue of self-image” (Psiq1); “You see yourself more and, therefore, I feel that it seems to be more difficult for them online” (Psi5); “Many say they do not want to look at the camera, do not want to be seeing themselves there, you know. They are uncomfortable all the time, worried” (Nutri1); “Many patients report that they do not like seeing themselves and sometimes hearing their own voice there. I think it is difficult” (TO1).

Research on online clinical care (Cardoso et al., 2022; Costa & Gomes, 2023; Sedlacek, 2022; Stukenberg et al., 2022) also highlights the implications of the image projected on the screen, both from the perspective of the psychotherapist and the people treated, who experience persistent concern about how they are seen or perceived through the screen. Psychology professionals evoked situations that relate to this issue: “There was a patient who had a lot of this issue of looking at the video, and she talked about it all the time: ‘I am seeing my face in the mirror, here in the video, and I see that my face is fat, I see that it is filling the entire screen.’” (Psi2); “And then she told me that sometimes she really wanted to turn off the camera because there were days when she felt very ugly and did not want to keep seeing herself” (Psi8).

Seeing one’s own reflection on the screen is like looking in the mirror all the time without being able to look away. The discomfort raised can also be a preverbal form of communication, since it requires the presence of another in the relationship to also see her seeing herself. Just as the face of the person responsible for primary care mirrors the infant’s internal states for the infant, the clinician can offer the mirroring function in the virtual frame, provided there is the possibility of polyphonic and reflective listening (Cardoso et al., 2022). The particularity of seeing oneself on the screen is that the mirroring function is not deposited solely in the clinician, the other in the relationship, but also in the image of oneself reflected. If this particularity is well managed, the mirroring function can be of great value for the clinic of narcissistic pathologies, as suggested by one participant in this study: “But I think maybe this can be managed and even, perhaps, brought into the session and discussed how it is for the person to be seeing herself there. Anyway, I think this should be included in the care” (Psi10).

The results of this study show that turning off cameras was generally perceived by the healthcare providers as an obstacle in online care. In the participants’ perception, presence in the digital environment is different, sustained by elements such as voice or the act of seeing and being seen, but this does not necessarily narrow the possibilities of the bond. Turning off the camera can also be an interesting factor for opening up to the symbolic, which could contribute to deepening the care process. On the other hand, it is necessary to keep in mind that, in cases of narcissistic suffering, this may also require management of the therapeutic bond in a way that keeps the difference active, which guarantees the inscription of the self/non-self boundary. This boundary can become more tenuous and blurred in the digital environment. On the other hand, keeping cameras on opens space to see oneself constantly, in a mirroring function at a persecutory level, which also demands appropriate clinical management.

Given this, it is necessary to consider the ethical position in management on a case-by-case basis when it comes to remote care (Benzel & Graneist, 2023; Cruz & Labiak, 2021). As Prado et al. (2021) argue, the same resource may be helpful for some people and a source of resistance for others, depending on the clinical management skills of the psychotherapist, which highlights the need for new studies on telecare to elucidate its implications and consequences. This applies to any healthcare provider working with psychological suffering, since clinical attitude is independent of the area of practice, academic training, or specialty (Roussillon, 2019). It is important to note that this study was conducted in the context of the transition and adaptation of professionals in a specialized service to the unusual demands imposed by the pandemic period. All the professionals had little or no prior contact with online care, adopting it on an emergency basis and, to a large extent, in an improvised and intuitive manner.

Final considerations

The results obtained suggest that the perception of the body is transformed in the digital context, highlighting the image itself or removing it from the view of the other. This has consequences from the perspective of the therapeutic bond, given that some professionals tend to perceive the image blocking caused by the camera as a closure by the patients toward the therapeutic relationship and treatment. The emotional experiences elicited by treatment without image can be distressing, as they favor the erasure of the self-other boundaries. On the other hand, from the patients’ point of view, this can also foster new openings for the bond, insofar as they feel they can reassume control over the anxiety-provoking situation. Conversely, they may also relive immersion in an undifferentiated emotional experience, re-editing patterns lived in the experience of an intrusive primary bond. The experience of “seeing oneself” constantly was another dimension highlighted by the professionals, with implications that may either favor treatment progress or constitute an obstacle to maintaining the bond.

Based on the meanings attributed to the most significant moments of the shared experiences, it was possible to reveal original results regarding bonding in the digital space and the implications of the body in the reconfiguration of the therapeutic bond, which has consequences for clinical practice. From the multiprofessional team’s perspective, treatment in the digital space proved fruitful, although it imposes some challenges for the management of the bond, which need to be discussed case by case and considered under an ethical framework. We emphasize the urgent need for further research on the subject, considering that the transition to the online model was conducted hastily and improvisationally due to the emergency scenario imposed by the health crisis triggered by the COVID-19 pandemic. It is also necessary to consider the consequences of COVID-19 as a disruptive event for healthcare professionals.

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• Data Availability Statement
  Research data is available on request from the corresponding author.
• Funding Information
  This article was funded by CAPES and CNPq.

Edited by

• Editor-in-Chief
  Tiago Jessé Souza de Lima

• Associated Editor
  Angela Marin

Data availability

Research data is available on request from the corresponding author.

Publication Dates

• Publication in this collection
  23 Mar 2026
• Date of issue
  2026

History

• Received
  03 Dec 2023
• Accepted
  26 Nov 2024