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COMMENTARY ON THE ECED MEETING IN LONDON ON THE 12^TH AND 13^TH

SEPTEMBER, 2009

DEBATE AS AN EDUCATIONAL METHOD

When Hubert Lacey invited me to open the meeting on the 12^th September I was naturally delighted. I felt privileged to welcome the participants who represented several nations. I also took the opportunity to highlight what has become the key feature of these meetings, namely the occurrence of debates. I anticipated that, as in the past, debates would generate powerful ideas and above all the discussion would be entertaining. I also anticipated that the format of the debates would be of high educational value. It turned out that I was right about the entertainment provided from the close engagement of the participants. But I was mistaken in my prediction of achieving an educational success.

My intention in presenting this mixed picture of the ECED debate is first to admit my limited powers of prediction and secondly to express honestly my disappointment as regards the limited educational success. I can make one safe prediction, and that is that my conclusions will generate disagreements. I am grateful to Gerry Butcher who has offered to have this commentary published on the EDEC website with an invitation to other participants at the meeting to respond. At this stage I wish to stress that no criticism is intended as regards the quality of the presentations, or the discussion. On the contrary, they were of an exceptionally high standard and led to a high level of engagement in the discussions. My criticism is mainly aimed at the format of the debates which on this occasion provided no resolution of polarised views and, even more disappointingly, failed to generate ideas from the available literature or suggestions for future research.

Debate One: “This house believes we should invest much more of our limited resources into preventing eating disorders”.

The protagonists were Runi Børresen and Greta Noordenbos. The opposer was Eric van Furth. (Unusually Eric opposed the motion on his own because the other opposer had met with travel difficulties).

My concern with this debate is that the motion deliberately omitted to define what was meant by “preventing eating disorders”. In particular a standard method of classifying types of prevention was not included. Consequently the proposers and the opposer quite shrewdly (and this is entirely fair) chose to select the type of prevention that suited their arguments. They did not disclose the three conceptual levels of prevention (primary, secondary and tertiary) proposed by Leavell and Clark in the late in1950’s, applicable to almost all medical conditions (quoted by Bertolote, 2009).

By primary prevention is meant preventing the appearance of the disease (or illness). It can be specific in type such as immunisation against an infectious disease, or non-specific such as improving the general health of the population.

By secondary prevention is meant the early detection and treatment of an illness with the preventive goal of avoiding chronicity and irreversible complications.

Tertiary prevention refers largely to rehabilitation whereby damage caused by the illness is reduced as much as possible and intact functions are preserved.

In the case of eating disorders attempts at primary prevention have so far included interventions for the benefit of adolescents in schools. But there has been a notable lack of success with these measures. Secondary prevention includes the early diagnosis of anorexia nervosa and the correction of nutritional abnormalities so as to prevent osteoporosis (for example). This would also apply to patients with bulimia nervosa whose illness would be cut short by an energetic course of cognitive behaviour therapy.

The proposers of the motion said it was very important to avoid severe weight loss and its complications, and recognised this as secondary prevention but ignored the limitations of primary prevention. The opposer to the motion quite rightly said that no one knew an effective way of preventing an eating disorder and evidently he was referring to primary prevention.

My conclusion is that both sides were aware of the obscurity of the wording of the motion and used the ambiguity to suit their own ends. To the audience the debate was like a Rorschach with each side reading what they wished in the ink blots.

Thus, my criticism is that the debate failed to elicit a classification of prevention for eating disorders. The proposers produced a list of references supporting their own arguments but did not summarise the evidence, or lack of it, for primary prevention. No doubt some of the audience saw their way through these obscurities but they would have benefited from a clarification of the taxonomy of prevention. This was an important educational gap in this debate.

Debate Two: “This house believes that information-sharing and carer involvement in the treatment of severe eating disorders should take precedence over confidentiality”.

The proposers of the motion were Fernando Fernandez and Susan Ringwood. The opposers were Erika Toman and Bridget Dolan.

The polarisation of opinion in this debate was very clear with extreme views being adopted. Eloquence was the hallmark of this debate. On the one hand there were dramatic accounts of extremely ill and depressed patients whose life would have been lost if there had been no sharing of information with the carers. On the other hand, the fundamental human right of privacy was presented as enshrined in European law and sacrosanct. The audience became fully engaged in asserting one or other extreme view with little room for compromise. The debate was exciting and even passionate at times.

In contrast, I thought that with the extreme polarisation of views there was a failure to explore a practical balance that should be reached in a clinical dilemma which is frequently encountered when treating eating disorders. On voting the motion was defeated, which means that in some instances the potential help from carers would be excluded. The dilemma is well recognised by family therapists treating adolescent anorexic patients. They become skilled at squaring this circle. It seems arbitrary, and wasteful, that after the legal cut-off age of 16 an adolescent patient could cut herself off from the help of an effective carer.

My one personal contribution was to admit that I did not know of any systematic research in the field of eating disorders to try to resolve the conflicts which are commonly experienced. In contrast there is a growing literature on how the participation of carers can be facilitated in the case of psychotic patients who do not consent to sharing information with carers (Slade et al, 2007). This research group at the Institute of Psychiatry recognised that carers require access to relevant information to support them in their role. Moreover, a “culture shift” is probably required to train professionals to work with carers. The article also points out that legal rights to confidentiality are not absolute. A useful practical recommendation is the distinction between general information about the patient, which can always be shared without consent, and personal information which is new to the carer where consent generally needs to be obtained. It is also important to record what the carer already knows, and keep an audit of the consent already given by the patient. Such practical advice can be valuable when clinical obstacles are met, such as an adolescent anorexic patient demanding that the clinician should not communicate with her parents or carers. Slade and his colleagues recognised that the sharing of information is a complex process, best balanced by clinical judgement.

My grouse about the second debate is that it was extremely strong in the expression of personal opinion but weak in recognising that in the field of eating disorders we need to emulate research that has already been achieved in other branches of psychiatry.

CONCLUSIONS

The two debates that took place at the Athenaeum were highly successful in engaging the audience, arousing interest and calling forth eloquent outpourings of opinion. They were both entertaining. On the other hand, they were both flawed in that there was insufficient recourse to established knowledge and no recognition of the need to inform opinion through research.

Gerald Russell

References

Bertolote, J.M. (2009). Primary prevention of eating disorders. In New Oxford Textbook of Psychiatry. Eds. M.G. Gelder, Nancy C. Andreasen, J.J. López-Ibor and J.A.R. Geddes. 2^nd edition, vol II, chapter 7.4, pp 1447-1451. Oxford University Press, Oxford.

Slade, M., Pinfold, V., Rapaport, J., Bellringer, S., Banarjee, S., Kuipers, E. and Huxley, P. (2007). Best practice when service users do not consent to sharing information with carers. National Multi-method study. Vol. 190, pp 148-155.

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