Science

Poet Fiona Hamilton reminded us in her beautiful performance on the Friday evening that medicine is as much art as science. Where does the mind begin?  No one tried to answer that, but there were a lot of figures and graphs and studies of the brain at EDIC. 

"Science" covers a wide variety of disciplines. RCTs on psychological therapies, MRI scans, mapping the genome, these were all in the programme. They were all mixed and matched with treatment protocols and the economics of funding and personal and family experiences too.

Although Dr Blake Woodside's talk was slap bang in the middle of the "biological factors" plenary he spoke as much about the novel treatments his team are offering as the science behind them. The first talk took us galloping through genetics. The presenter had problems with her slides and there wasn't enough time to cover such a vast topic. The third talk was very technical. Maybe it was because by the Saturday I was tired but I didn't take many notes during that plenary. That didn't stop genetics being a topic of conversation throughout the three days and science being centre stage. The Charlotte's Helix stand did brisk work with their spit for science which caught the imagination of many

The short papers on the Thursday weren't supposed to be about science. I went to the ones specifically labelled as "treatment".  However as a whole they spoke to me of science. One was on training which may be more art, but the three on controlled trials, randomised or otherwise were fascinating to compare. One was a full Randomised Controlled Trial comparing two therapies used on a hard to engage population in the community. The others were therapies given to inpatients that were studied without a control. The presence or otherwise of a control group wasn't the most telling factor. The inpatients (who spent the time of the trial unable to get out of it and being restored to a healthy weight) completed their treatment and seemed to benefit from it. The outpatients mainly failed to stay in the trial. Does that mean that the two IP treatments were effective and the OP not? No way. How on earth can you begin to separate out the effects of refeeding and of all the other therapies given IP from the specific treatments.  Did it mean that the OP treatments held no hope. I don't think so. Surely it meant far more that hard to engage, long term patients need more support in the community to access and continue in treatment (and probably quite a bit of refeeding too).

The last short paper was on the medical complications of severe AN. Patients admitted to an adult ward, often with long histories of the illness, had their medical records scrutinised to see what the physical effects could be. They turned out not to be very well.  While this should be blindingly obvious to anyone who knows anything about the illness this was one of the few studies that has actually studied AN from a medical point of view. Why is that? Why did it seem odd that among the flyers for books and the adverts for private treatment centres in our delegate packs, there was a brochure for medical scales? Therapists may wish to ditch the scales but they are ONE of the important tools in assessing physical health. Why is the data on eating disorders so poor that no one has a clue how many people suffer from them in the UK let alone in the refugee camps?



 

Treatment

One of the problems of writing up my experiences of EDIC under themes rather than chronologically is that the themes overlap. Janet Treasure's work isn't a treatment, but many of the other family interventions I discussed yesterday are. 

 Ivan Eisler even gave us a history of, and two names for, the treatment he was discussing (the link goes to an older presentation on a similar theme). We were whisked through a history of FBT (or FT-AN), introduced to the three treatment manuals (going backwards Eisler's own, Lock and LeGrange and an older, unpublished one by Robin and Siegler). All three stressed working with the family, gave the parents centre stage in helping the child and encouraged separation of the illness from the child. The differences included the order and number of phases of treatment. Eisler has developed an initial phase of engagement of the family and rejects the word "empowerment". It's true, it's a word that doesn't trip easily off a British tongue and the idea that parents are being helped to be effective in caring for their sick child, rather than powerful in a battle against a monster resonated with me even if I know that others will find it confusing.

The other treatments covered in plenary sessions were CBT-E, MANTRA and effective treatment for BED. To be honest, these sessions coming after both lunch and Janet Treasure's keynote, I was a little too sleepy to really take them in. Byrne talked well about CBT-E but her main arguement, that figures for its effectiveness are not inflated, was made in a poster in the stroll. I was so interested in the history of AN with which Schmidt introduced her talk on MANTRA that I rather missed the description of the actual treatment and while the evidence is enormous that BED is very treatable my main take-home from the German talk was that funding would never be granted for such treatment in the UK as the only disappointing result was a lack of change in BMI.

I was very, very lucky to be able to go to the whole conference but not have any work to do. This allowed me to pick and choose the workshops I went to on the basis of personal interest rather than anything else. Therefore I don't know how the talk on Specialist Supportive Clinical Management  went or even what a Recovery Oriented Approach for Eating Disorders really is. I am interested in DBT, so I went to two talks on it. The British team were great. They explained what they did. They gave us practical examples. I didn't NEED to go to a second talk but I'm so glad I did. Dr Fragiskos Gonidakis seemed to have that special quality that people like Janet Treasure have, a passion for the work and a real liking for his patients.

Family Values

My original reaction to the EDIC programme was negative. There appeared to be sessions about families but I wondered whether these would be in any way positive.

OK, Janet Treasure and a parent carer were giving a keynote but would this would be a tickbox gesture, a description of how you could herd the frightened parents into a pen like the rhinos and ostriches that they are and thus avoid the awkward business of having to deal with their unhelpful suggestions and complaints?

Much more worrying was the emphasis on "Attachment". Having seen that an author who has deliberately challenged modern thinking on the role of the family and hurled it right back into the dark ages, was presenting on attachment, I feared that the keynote on the subject would also be strong on  blame. It wasn't. In an engaging and amusing speech Dr Fonagy outlined the importance of attachment and argued that youngsters with poor "theory of mind" may use ED symptoms as a way of social regulation and that "Mentalisation" MIGHT be helpful with this but he deliberately avoided blame and made no boastful claims for his ideas over anyone else's.

Treasure and Langley's keynote couldn't have been used as an excuse to sideline parents away from the "main action" by any but the most dyed in the wool blamers. I heard that it was completely enlightening to some health economists who hadn't previously factored in the costs and benefits of family involvement. It concentrated on the isolation brought by the illness, especially as it became entrenched in longer term sufferers, and the need of families for practical skills. Langley brought up this point again in a question to Ivan Eisler on the third day. His talk on this history and development of family based treatments was part of a trio including news from France and Germany. His assertion that telling the parents "you know how to feed your child" and then leaving the parents to do it all alone isn't FBT was quite accurate, but it IS how all too many families in the UK experience it. By contrast parents in Germany are undoubtedly under-utilised, if not disempowered, by their system of automatic admission or day patient, but it is an immediately safer way of dealing with these life-threatening illnesses than some of the things that go on in the UK.  

I did hear criticism of parents, from patients that their illness was their business, from a counsellor that parents refused to acknowledge their children's illnesses, from a clinican that "parents get these ideas off the internet". These dangerous ideas turned out to be the NICE guidelines which in my mind couldn't be woollier if they were knitted from yarn, but the clinician had felt threatened when they had been used against him. However I didn't hear any of them during the attachment workshop. I expected to hate it and, as I put on my feedback form, my expectations were fully met, but it was billed as  teaching how to engage families in treatment, not "how to blame your mothers" and most (but not all) of those there seemed to be willing to swallow the theory in order to get to the practice. There was at least one other mother there, and apparently she loved it. I reluctantly have to conclude that perhaps parents are so desperate they will accept anything. I know I was when we went through our family therapy days. What can we do about that?

I'm back

I am back on this blog after nearly a year (it took me ten minutes to re-learn how to start a new post) and I'm back home after 3 very hectic, tiring, and enjoyable days at EDIC.

The combination of having had to concentrate so hard on so many talks over the last week and landing back in real life with so much to do has made me feel like some catherine wheel that has come off its nail and is spiraling out of control to the ground. I expect with sleep and food and some of the other self-soothing techniques I've be learning about I will recover. However the spiral is quite a useful illustration about how I intend to reflect on what I have learned - from the middle out.

If I just went through each talk in chronological order I would bore even myself to death. I intend to write four blog posts only, starting from the heart as in mid point on the middle day and as in the family who can be at the heart of treatment (or excluded, or left to muddle through alone, or only welcomed so that they can say sorry). I will go on to treatment approaches, science and lastly coming back round to economics which as the chair of the conference pointed out is always near the heart of political thinking in health provision.