James Lock, MD, Ph.D Professor of Child Psychiatry Stanford University
How did we get here? Historical Context Training Biases: How did therapists get here? Family Biases: What do families expect? How can we move forward? Challenges to changing attitudes and practices
The child is exposed from "the beginning to parental coldness, obsessiveness, and a mechanical type of attention to material needs only... They were left neatly in refrigerators which did not defrost. Their withdrawal seems to be an act of turning away from such a situation to seek comfort in solitude. Leo Kanner, 1943
"The difference between the plight of prisoners in a concentration camp and the conditions which lead to autism and schizophrenia in children is, of course, that the child has never had a previous chance to develop much of a personality. Bruno Bettelheim
we suggest, the double-bind nature of schizophrenia results in place a child in a position where if he responds to his mother s simulated affection her anxiety will be aroused and she will punish him to defend herself from closeness with him. Bateson, et al, 1956
Sir William Gull (1816-1890)
Jean Martin Charcot (1825-1893)
excessive concern with the body and its size, and the rigid control over eating, are late symptoms in the development of youngsters who have been engaged in a desperate fight against feeling enslaved and exploited, not competent to lead a life of their own. Hilda Bruck
Psychosomatic Families: enmeshed, rigid, anxious, over involved
Based in theoretical models Many of these models are untested Psychodynamic models are untested but strongly held Focus on causation/etiology, but little data support suppositions Treatment based on putative causes often biased against families Instructors/time to change
Psychiatrist may be particularly challenged to work with eating disorders (fewer opportunities to work with this population) Lack of clear effectiveness of medications Lack of family therapy training Turning it over to psychologists/family therapists Few child psychiatrist and these disorders mostly onset in adolescence
Concern/anxiety of co-morbid medical problems Insufficient training in specific therapies for eating disorders Lack of exposure/experience with the eating disorder patients Preference for individual approaches?
Developmental disorder Parents over controlling Professionals better than parents Institutions better than parents Losing/finding my way Prophet in his own land Re-institutionalization
Limited data for evidence-based practice Clinician s resist manualization as cookiecutter and not real world System problems diagnosis, reimbursement, administrative/clinical/physical structures Limited training/methods for dissemination of EVP Specialists/Guild issues/accessibility
65% (26/40) discussed their reluctance to commit to an evidence-based practice, stating one size does not fit all 75% (30/40) felt it was imperative to involve parents
Administrative Buy-In I think that s where the individual organizations have to make a commitment to supporting their staff because if they re working in eating disorders then they need to actually provide their staff with the training so that they can deliver the best treatment possible Team Buy-In Definitely our treatment team if they re not on board then that makes it a little bit difficult to formulate a treatment plan that they don t believe in.
Want to know cause Guilt and blame overt and covert Feel unprepared/unable to take on problem at home Non-responders what next? Realistic expectations?
Agnostic view of cause of illness (Parents nor adolescent are not to blame) Non authoritarian therapeutic stance (Joining with family) Parents are responsible (Empowerment) Externalization (Separation of child and illness) Initial focus on symptoms (Pragmatic)
Embrace agnosticism/humility (nonauthoritarian stance) Empower oneself to learn Accept consultation Externalize the problem (separate the disorder from the treatment) Focus on symptom change
I do not consider it an insult, but rather a compliment to be called an agnostic. I do not pretend to know where many ignorant men are sure -- that is all that agnosticism means. Clarence Darrow "Extraordinary claims require extraordinary evidence." - Carl Sagan In all affairs it s a healthy thing now and then to hang a question mark on the things you have long taken for granted. Bertrand Russell If you see a man approaching you with the obvious intent of doing you good, you should run for your life. Henry David Thoreau When I told the people of Northern Ireland that I was an atheist, a woman in the audience stood up and said, "Yes, but is it the God of the Catholics or the God of the Protestants in whom you don't believe? Quentin Crisp
Possession Model
Treatment Process
Empowering Families with knowledge Parental Advocacy overcoming stigma (perhaps our biggest obstacle Research in EBP (demand therapist practice it depand research to develop new treatments) Research in dissemination Targeting professional education Professional meetings, graduate schools, post-doc training programs