The following is a transcript of a talk from the ANZAED Debate 2024.
Why Evidence Based Practice Limits Innovation in the Treatment of Eating Disorders:
…my story starts as a naive DBT clinician NOT specialising in EDs. Hearing rumours of some of the DBT folk overseas combining FBT AND DBT, and serendipitously Prof Jim Lock was in NZ so I jumped onto his training, thinking that sounds cool!
As a younger CAMHS therapist with starry eyes and FREER REIN I didn’t appreciate what a lofty goal this was. because you see, in the eating disorders world of using SCIENTIFICALLY PROVEN METHODS, if the treatment wasn’t backed by evidence, it wasn’t the done thing…We did it anyway, but my goodness that was a turbulent start to my eating disorders career! And I have NEVER acquired more treatment manuals in such a short space of time in my life. Ever.
We know that certain presentations are more likely to have poorer treatment outcomes, …. sequential siloed treatment of co-occurring problems are less helpful etc etc. I shall skip over that because you. Have. Heard. It. All. Before.
It is SO disheartening to watch the proverbial ‘tennis match’ when our clients go between specialist ED service to general MH or addiction service and back again, not receiving much treatment but collecting diagnosis and losing hope along the way.
Multi-diagnostic ED – DBT (MED-DBT for short) is what I do with my time these days. It is one example of an innovative solution for this problem for adults. Yet despite the clear need, dissemination has been slow due to difficulties in producing the ‘right’ type of evidence. You see, MED-DBT clients are the ones who tend to be excluded from the studies, so it gets a bit tricky to undertake comparative trials.
I am incredibly fortunate to be able to do so much innovative practice in my clinical work in Aotearoa, but this is not the case everywhere. My thoughts here are related to the broader context of eating disorder treatment development, research and dissemination.
I have spent 12 years working to develop, train, implement and more recently disseminate DBT for multiproblem restrictive eating disorders and one of the biggest barriers over the whole time is the narrative of it not being evidenced based. This statement is not only reductionistic, it also shuts down conversation, problem solving and opportunity. MED-DBT is built on 20 years of translational evidence and research about what works for the clients whom we use it for. It isn’t a scientifically proven model for Anorexia – yet. I’d love it to be – but the researchers are all busy now with the CBT publications…
I admit at times I do feel like the rogue therapy cowboy, breaking the rules set by the sheriff of ED treatments [quiet into microphone] (If anyone knows who that is, please give him my card? He seems to have a LOT of influence) yet at the same time….one must wonder… at what stage does it become UNETHICAL to withhold a potentially efficacious treatment when all other avenues have been exhausted?
I share concerns about model adherence and treatment [loud/knowing voice into microphone] “DRIFT”, And I truly believe we don’t know for sure who will and won’t respond to treatment, so people should be offered the first line treatment FIRST. Provided to proficiency [knowing look to audience then pause]….…But come on! sometimes it’s the treatment that fails!! THEN we need to figure out how to do better.
Given the limited treatments on offer globally, it stands that we are expecting all people with EDs to be the same and respond accordingly, when it is clear – as is so evident from the content at this conference – this is not the case. And why are we continuing these same interventions for our clients repeatedly for years? What’s the threat in expanding the repertoire?
Yes, let’s start with the evidence. But somewhere along the way the pendulum has swung too far. there is a level of ‘reverie’ and ‘status’ attached to scientifically proven therapy models that isn’t justified by treatment outcomes. And it seems we have conflated ‘therapy models’ with ‘evidence-based practice’, as if they are synonymous concepts, resulting in only a select few treatment models getting a ‘seat around the table’. This vastly limits opportunities for different approaches to be seen/heard . This bias perpetuates beliefs that those who do not respond are “resistant” or “unmotivated” when in fact, they require different approaches to their care. This bias impact those in minority & marginalised populations. We have heard their clear messages this week. There is more than one way of ‘knowing’ and multiple types of evidence and we MUST start listening and making space.
The literature questions the ethics of potentially coercive treatment practices when ED services become overly constrained by evidenced based models. How are punitive consequences, and withholding treatment more ethical than offering a different treatment, that is grounded in scientific principles, informed by evidence and showing promise in case series?
Look, I know we have scarce resource, and we cannot block up services when there are waitlists of people who may respond. And that is EXACTLY why we need more diversity of treatments, more innovative solutions now! Alternatively what else do we do? It is of huge concern when instead of thinking more broadly about those not responding to traditional treatments, there is consideration at all to labelling these folks as “terminal” [long pause]
So yes, evidence-based practice, when constrained by our own definitions of what this means, can and does limit innovation in the treatment of ED. it impacts our practice, how and what treatments are delivered in our services, it governs our clinical decision making, it influences where funding goes and what is accepted for publication and thus how knowledge is disseminated and through this incentivises gatekeeping.
My view is that we need to be more dialectical – hold space for more than one reality – both uphold and build on EBP AND look for radically different realities, find truth in the most surprising places, be open to trying things out without judgment. We need to be effective, and being effective doesn’t always mean being ‘right’.
I used to be quite black and white about EB TREATMENT And yet here I am now,
The proverbial therapy cowboy [PUT ON COWBOY HAT NOW] doing my “UN-scientifically proven” treatment and asking for a space around the table.
Nga mihi nui!
ANZAED Debate 2024