Reflecting on the 2014 International Conference on Eating Disorders

Tetyana’s Note: Instead of writing two separate posts, I’ve decided to interject and add my own thoughts/opinions to Andrea’s post. For one, I think this will reduce repetition and I think it will be better to have any differing opinions in one place (I think this will facilitate discussion, I hope).  I will clearly mark my own comments so that they are not for conflated with Andrea’s. If I don’t comment it is because I wasn’t there, have nothing to add, or completely agree and thus have nothing/little to add. Admittedly, I’m going to focus more on things I didn’t like because I think it is important to talk about how the field can improve. – Tetyana

I am finally writing down some thoughts and reflections from ICED after taking a week to marinate on the proceedings and to grade a lot of papers. I love going to conferences — I’m a big fan of live Tweeting and it is always great to meet new people and/or “Internet people” in real life. That said, there is something inherently exhausting about the conference environment. Coming home, I needed a moment to breathe and reflect — a moment I didn’t really get, as my return happened to coincide with the end of the semester and some big news. So those are my excuses for tardiness in preparing this reflection.

I feel very thankful to have been able to head down to New York City for five days and to spend three of those in the company of about 1300 others who, I truly believe, are all ultimately committed to helping individuals with eating disorders through research and/or practice.

Tetyana’s thoughts: and science/research blogging. I was also glad to spend a few hours with Andrea at MoMA. Totally developed a new appreciation for Gauguin.

I want to be clear from the outset how grateful I am to be doing exactly the work I feel passionate about and am honoured to have had the opportunity to present at the conference. I love eating disorder research; I love interacting with researchers and clinicians from around the world who do amazing work every day and who come up with ideas I’d never have dreamt of.

I think it is important to acknowledge the collective empathy and intelligence that filled the rooms at ICED. Again, a caveat: I think we could be mobilizing this collective inspiration toward making change. These are just a few things to keep in mind when reading (or just skimming through; do what you will) my reflections. I will blog about specific papers presented in the near future, so consider some of this a bit of a “teaser,” if you will.

WHAT I LIKED

Let’s start with the positive. My favourite sessions were, quite predictably, those that took a more critical slant and those that offered the opportunity to learn from disagreement. What do I mean “learn from disagreement”?

Family-Based Treatment Debate

The best example I can think of is the debate on Family Based Treatment (FBT) between Dr. Daniel Le Grange and Dr. Michael Strober. Both highly respected researchers came together to discuss not only the ins and outs of FBT, but the way that it has been taken up in the popular imagination.

Dr. Le Grange is one of the originators of the manualized FBT approach (one reason for which I was extraordinarily anxious that he chaired the session I presented in, but I digress). In the debate, he presented FBT as an evidence-based approach that is helpful in promoting weight restoration, particularly among adolescents who have high scores on the Eating Disorder Examination Questionnaire (EDE-Q). He was very clear, however, that “FBT is by no means a panacea.”

Dr. Strober, on the other hand, has gained somewhat of a reputation for “speaking against” FBT. Dr. Strober presented what he referred to as a nuancing of the “glossy language” around FBT. He encouraged the audience to revision the meaning of “evidence-based,” and took time to unpack some of the studies commonly cited in literature encouraging the use of FBT (e.g. Russell et al., 1987). Rather than suggesting that FBT is never effective or that it should not be used, he problematized the unquestioning uptake of FBT by practitioners and in the popular imagination.

Dr. Strober’s talk was underscored by a focus on evidence-based medicine as articulated by Sackett (1997). Importantly, this perspective on “evidence-based” practice includes not only evidence from randomized controlled trials with strong sample sizes, but also individual experiences. I thought this was very interesting; as Dr. Strober continually reiterated the idea that “anorexia nervosa is a uniquely complex illness,” it makes sense that he would draw on a framework that acknowledges unique and multi-faceted experiences of eating disorders.

Tetyana’s thoughts: I think one particularly important point raised by Dr. Strober was the lack of attention paid to expressed emotion, particularly as a contraindicator. Dr. Strober was clear that he suggests FBT for some families/patients but he cautioned against prescribing it to every family.

He said that he (and others he knows) has been accused of “hating families” (to which he said something along the lines of, “As far as I know, the only family I hate is mine; I quite fancy others”) and of being unethical in not prescribing FBT. He also expressed concern about un/under-qualified clinicians/therapists providing FBT, saying that he teaches his trainees to “never underestimate the incompetence of mental health professionals.” (Ditto!) As he said, AN is an illness that can go from nothing to very severe at an incredible speed and so there’s really little to no room for error; he said he has seen families engaged in FBT for a year or more with clear signs that it is not working. This is obviously not good (to say the least).

The other point that he raised (and that Dr. Eric van Furth raised in a completely different conversation) was that absence of evidence is not the same as evidence against/no evidence. It takes a lot of money, time, and resources to conduct randomized-controlled trials. I think Dr. Le Grange said their study cost $3.5 million (someone correct me if I am wrong). It is hard to get funding, especially for eating disorders, and even with funding, it is hard to recruit and retain participants, and train all the staff. And, as Dr. van Furth said to me, “one RCT is no RCT.” But we can’t sit around and wait until we have ample evidence for what does and doesn’t work. There’s something to be said for clinical experience, especially decades of clinical experience.

Dr. Le Grange also noted that the search for evidence-based treatment is not a “two horse race”; that is practitioners would ideally be able to match individual patient needs to appropriate treatment. Perhaps the reason FBT has sparked such interest, he suggested, was that in a field ripe with dissent about treatment options, FBT has some evidence behind it.

One of the key things about this debate, in my opinion, was the willingness that both speakers (and many audience members) displayed to accept critique, consider alternatives, and engage in compassionate dialogue that ultimately aims to provide the best for patients. Rather than tearing each other down, this level-headed debate allowed for a nuanced discussion of often taken-for-granted treatment modalities.

Audience members also nudged Drs. Le Grange & Strober to write a paper together that would help to bridge the polarized camps “for” and “against” (though, again, there are many more shades of grey, here) treatment options. I’d love to see this actually materialize. [Tetyana’s thoughts: Polarized camps that, everyone agreed, mainly seem to exist in non-academic circles. Dr. Le Grange, speaking after Dr. Strober, said he agreed with “95%” of what Dr. Michael Strober said in his presentation.]

Prevention & Public Health Paper Session

Another favourite moment for me was one of the Oral Paper Sessions, Prevention and Public Health. By this point it was Saturday afternoon and my energy was flagging — there was surprisingly little food at this conference — but I settled into an oral paper presentation hoping for the best. This session included talks by Jessica Murakami, Rebecca Puhl, Victoria Freeman, Jessica Yu, Sian McLean and Heather Thompson-Brenner.

Rebecca Puhl (of the Yale Rudd Centre) explored policy options in response to weight stigma. Presented with a variety of potential policy options, both the general public and practitioners endorsed policies that would address health care, schools, and media. Few supported policies that would weigh or measure children, which is very reassuring- sometimes it seems as though everyone is on board with weighing and “BMI report cards”- which disturbs me because no one has proven these kinds of measures are effective (and some have shown the reverse effect).

Other presentations, including those by Freeman, Yu & McLean, looked at stigma in the context of eating disorders. Freeman’s talk explored the impact of perceived stigma around AN. She and her co-authors found that participants felt their illness only “counted” when it was visible, that AN was often trivialized and misunderstood, and that the extent of stigma was so strong that some participants would pretend to have a different illness when in treatment.

Yu and colleagues explored stigma against men using performance-enhancing drugs, finding that health care practitioners endorsed more stigmatizing attitudes toward males using performance-enhancing drugs than against male eating disorder patients, followed by cocaine users. McLean and her co-researchers looked stigma against individuals with bulimia and how this stigma may impede treatment-seeking.

In perhaps my favorite talk in this session, Thompson-Brenner et al. looked at the language of morality and contagion that surrounds discussions of eating disorders in media. For example, think of tabloid magazines that spout headlines saying things like “Eating Disorder Confessions!” and depict emaciated celebrities.

This kind of frame reinforces the problematic assumption that everyone is equally vulnerable to developing eating disorders, and reduces the complex and intersecting causes of eating disorders to thin-ideal internalization. This study investigated blame and contagion; the authors found a high fear of contagion related to anorexia, and individualizing blame for binge-eating disorder.

These discourses around contagion and blame also circulate when we think about obesity; it would seem that people always want to refer to things as “epidemics.” Framing complex issues in this overly simplistic way is troubling and suggests that we are all always in a state of vulnerability against ill health.

This is far from an exhaustive list of all the sessions I enjoyed over the course of the three days; I also enjoyed some workshop sessions and talks about Health At Every Size, Adolescents and the Media, and Prevention. These might form the basis of future posts, but in the interest of not boring readers I will move on for now.

So, I obviously just drew a parallel to “the obesity epidemic,” which might be a bit ironic as I move to what I enjoyed less…

WHAT WAS MISSING

Critique

The opening plenary of the conference was entitled “Disordered Eating and the Threat of Obesity: Shared Underlying Biological and Psychological Mechanisms.” Many sessions over the conference explored both eating disorders and obesity, reflecting on how public health approaches have been shifting to a focus on anti-obesity messaging. While much of this discussion was (I think quite rightly) focused on a critique of this kind of messaging, there was more problematizing to be done.

As several Tweeters at the conference noted, this kind of messaging makes working for eating disorder recovery much more difficult. When our main public health organizations in the (Western) world are working to “fight obesity,” important work toward eating disorder prevention and treatment can become relegated to second place. I felt like this opinion was common among Tweeters and in conversation; however, are we doing any better when a conference on eating disorders begins with a plenary session focused around “the threat of obesity”?

I am not trying to be a nay-sayer or to critique the hard work of the conference planners; certainly, the intersection of obesity and eating disorders is of interest to many (and the standing-room-only status of the plenary room attested to this). The plenary explored important issues and clever work about gene-environment interaction in producing altered weight and nutritional statuses, including evidence that dieting is ineffective.

However, some of the talks unproblematically accepted the idea that obesity is an epidemic and that both obesity and eating disorders are “rapidly increasing.” It seemed, at times, that sociocontextual factors were glossed over.

For example, a few questions that came to mind while listening to this plenary session:

– Is it possible that rather than seeing a rapid increase in eating disorder diagnoses in China, we are instead observing an increased incidence of recognition and diagnosis?

Tetyana’s thoughts: As I’ve blogged about before, whether eating disorders are increasing or not is not so clear-cut.

– Are there other measures we can use rather than BMI to conceptualize “risk”? [Yes…]

–  Rather than seeing obesity as an “oncoming tsunami” (yes, those words were used), can we see weight stigma as the oncoming tsunami and work against this?

– What kinds of socio-cultural factors could be leading to the “increase in” eating disorders that go beyond “Westernization” of appearance?

– To further situate eating disorders and obesity in socio-cultural milieu, can we attend to the capitalistic drives that underlie neoliberal society: for example, the notion that we exist in a society that sells excess but expects control

There were certainly questions that reflected a more critical perspective on “the obesity epidemic” and the ties to eating disorders. However, I am also wary of the way that having this plenary as the opening session could be interpreted by media, for example, who could co-opt messages to lump obesity under the category of “eating disorders.”

Tetyana’s thoughts: I personally did not feel like sociocultural factors were missed (perhaps not to the extent Andrea did) but I did find it frustrating (in addition to everything Andrea mentioned above) th while there was acknowledgement of the effects of globalization, interventions that were mentioned (literally: “fat camp,” and “acupuncture” – I’m not joking) are not only (i) CLEARLY ineffective, (ii) may actually promote/lead to eating disorders/disordered eating (in the case of dieting), but also (ii) FOCUS ON THE INDIVIDUAL. This, of course, has the effect of putting the responsibility on the individual.

I thought that, given the inclusion of binge eating disorder, it would be much more appropriate to start the conference with talks about binge eating disorder as opposed to obesity. To me, talking about obesity was almost like talking about underweight. Obesity is not a psychiatric disorder and not everyone (by far) who is obese has an eating disorder.

I also did not appreciate the mention by one presenter, clearly as a joke, but still, that we should just figure what brain parts make it hard for patients with AN to gain and maintain a higher weight and what parts make it hard for obese patients to lose and maintain a lower weight and switch them. I didn’t think that was appropriate humour for a professional, academic conference.

To be honest, I was also surprised at how few of the authors I regularly read and cite who take a more critical feminist perspective on eating disorders were present and/or cited. I would love to see more discussion between critical, feminist, and more “mainstream” approaches to understanding and critiquing eating disorders.

As I’ve alluded to, I think we learn the most when we disagree with others and challenge the status quo. Measured debates can bring together great thinkers who approach complex or “wicked” problems from multiple angles. Through this kind of discussion we can learn from expertise not our own.

For example, there is some great work ongoing in the field of genetics, neuroimaging and other very “hard science heavy” fields. There are also spectacular critical feminist explorations of the lived experiences of eating disorders. What would happen if we brought together these seemingly disparate fields to explore how the brain interacts with sociocultural environments to produce outcomes? It’s happening in (some of the) literature; I’d love to see this play out in face-to-face settings.

Le Grange said “we are a feisty bunch of people”; Strober noted that “our field is very insular.” Dr. Phillippa Diedrichs, talking about prevention and body image, suggested that we need to “get creative, strategic, and political.” So why not engage? I think it highly unlikely that this would lead to an all-out brawl; more likely a deeper and more impassioned understanding of the complex experiences and needs of diverse individuals with eating disorders.

Tetyana’s thoughts: In addition to what Andrea wrote above, I was also:

– not pleased with the amount of times I heard “anorexics/bulimics” in reference to groups of patients. I felt like I was reading a paper from the 80s.

– thought that the discussions about social media/”eating disorders online” painted online communities as very homogenous places and as places that are somehow qualitatively different from communities/spaces that exist in real life. They are not homogenous, static, or unlike “real life” spaces.

– I had issues with the way that body image disturbances/”love your body” rhetorics were also framed (from what I heard). I ranted about that here.

– how many presentations (even by researchers I really admire) had unnecessary images. First of all, given how many people in the room had (had) eating disorders, showing emaciated images may be unnecessarily triggering. But even without that: What’s the point? We all know what you are talking about. Oh great, another picture of a fat kid eating McDonald’s. Another picture of emaciated Nicole Richie. I know putting images on PowerPoint slides is considered good strategy in general but I don’t think that’s the case here. I just don’t see the point of the images we see time and time again.

– very pleased for the time I spent talking to and meeting awesome people. A shoutout to Dr. Stephanie Zerwas for being awesome. 

I had more thoughts but this is epic, so yeah. I’ll stop.

To end, here’s a photo of us (taken by Dr. Cristin Runfola):