2012 ICED Thoughts, Part One

I have lots of notes and lots of thoughts from the recent AED conference in Austin (known more formally as the International Conference on Eating Disorders, ICED). Because I have pretty sucky skills at summarization, I'm going to present my thoughts in several blog posts rather than trying to spit out concise and witty one-liners about the conference. As well, my obsessive nature also compels me to present the summaries in the order in which I attended them.

If you want to hear about the conference in 140-character snippets, you can look at my Twitter feed or just search the hashtag #iced2012 on Twitter. I'm not sure how much longer the hashtag will be searchable, but you should have at least several days to pull up everyone's tweets who attended the conference.

The conference opened with a keynote talk by Scott Lilienfeld, a psychologist from Emory University. Although Lilienfeld is not an ED expert, he does know a lot about evidence-based treatment and the myths of psychology. Lots of non-psychological myths abound, and Dr. Lilienfeld enlightened us on many of them. For instance: Napoleon wasn’t short (he was about average height for his time), lemmings don’t commit suicide (the famous Disney scene from a 1950s nature documentary was actually totally orchestrated- the films producers basically herded the poor darlings off a cliff), Paul Revere didn’t shout “The British are coming!” (Revere was British- there wasn't yet a distinction between British and American. He likely shouted something about Redcoats or regulars, but Longfellow took many poetic licenses in "The Midnight Ride of Paul Revere," not the least of which was that Revere didn't actually ride the furthest. Revere's partner did, but his name didn't rhyme as easily), and Nero didn’t fiddle while Rome burned (the fiddle wouldn't be invented for at least 1500 years).

The main focus of the talk was about the importance of integrating research into psychological treatments, and Lilienfeld called the science-practice gap in EDs "substantial." He outlined two major reasons for this: 1) a clash of worldviews and 2) misconceptions about science in general and empircally-supported treatments (EST) in particular. Part of the problem, he said, was a disagreement about what types of evidence are valuable. Romanticists, as Lilienfeld calls them, use intuition, personal experience, and emotion to evaluate the world. Empiricists are basically data wonks. They're a little more mistrustful, and rely upon data and more measurable items to figure things out. Neither is inherently better than the other, but Lilienfeld said that empiricism is essential when determining which treatments will work and for whom. (Romanticism, he noted, has been crucial to developing new treatments and hypotheses.) Clinical experience and observation are invaluable, but they don’t have a role in ascertaining whether treatments work. We need more rigorous studies.

While I think that the use of evidence-based treatments is pretty much a no-brainer (I'd rather pay for a treatment that we know works more often than some other form of treatment), that's not always the case for many psychologists. They say that EBP (evidence-based practice...you have officially entered acronym hell...) stifles creativity, and requires a cookie-cutter approach. Not so, Lilienfeld says. A good clinicians knows how to incorporate flexibility within fidelity (that is, using the principles of a treatment paradigm while tailoring it to fit the needs of the patient). This statement reminded me of a blog post from my dear friend June Alexander, which noted that "manuals don't treat people." Instead, research is more like a blueprint. Lilienfeld also poin some psychologists say that EBP is not helpful because everyone is unique, isn’t needed because we can judge therapeutic efficacy with experience and intuition.

Not so. Lilienfeld noted several psychological fallcies that ALL humans are guilty of. One of thee major ones is confirmation bias, in which we seek out evidence that supports our views and discounts the evidence that contradicts it. {{Besides EBT, confirmation bias is very prevalent in ED treatment. I had many therapist assume that I was abused, that my mother was over-controlling, that my family was toxic, just because I had an eating disorder.}} One of my professors in grad school put it a little more succinctly: "You tend to find what you're looking for." Once we have a hypothesis, everything is seen through this overriding scheme. If you want to see evidence for treatment success, you'll find it. Both patients and therapists tend to do this, which might be why both patients and therapists tend to rate a treatment as effective, even when it wasn't.

Another fallacy is known as illusory correlation, where we see a correlation between two things that isn’t there or exaggerate the magnitude of it. Two examples are the now debunked link between vaccines and autism, and full moon effect. More specific to eating disorders, Lilienfeld said, is the relationship between bulimia and childhood sexual abuse. There's some correlation, in that childhood sexual abuse probably increases a person's risk for any number of psychiatric disorders, but this relationship has been over-exaggerated. Several studies have found that people with BN didn't experience sexual abuse any more frequently than people without BN. Lots of clinicians and researchers think it’s extremely strong or a causal link. It's like when you're running late, and this is the only time that you're driving and the traffic lights are all red. There's not some demonic guy at the DMV tinkering with the lights, Lilienfeld. You just remember the red lights more because they're what's getting in the way of you arriving at your destination.

In the end, Lilienfeld proposed a partial solution of falliable humility. The core assumption is that essentially all individuals in the mental health field really want to help other people, but they disagree about how to get there. Lilienfeld emphasized science as best way to get there- rooting out wrong beliefs and errors, realizing that we can make mistakes. So often our claims outstrip the research evidence. We don’t understand what we can and can’t do. Science is a prescription for humility, but scientists can come across as arrogant and dismissive. Scientists aren’t necessarily humble, but science IS. As Carl Sagan put it, a scientist always have a little voice in their head saying “I might be wrong.” Poor clinical care, Lilienfeld said, comes from overconfidence, overreliance, and not checking out errors. Research methods are a way for correcting for mistakes. Psychology needs to incorporate science not a top-down approach- not just “research says…” but a way to check for their mistakes.

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Jennifer said...

Carrie, I'm taking a course currently on the law. The first lecture presented much of what Lilienfeld discusses re human bias so I've included a link to the paper by Barack Orbach on regulation: http://humanities.arizona.edu/sites/default/files/Barak%20Orbach--Regulation%20%28PDF%29.pdf

Jennifer said...

Great review, btw. Am looking forward to the rest of your reports. Thanks!

hm said...

We do all see the world through the lens of what we already think is probably true, whether that be the lens of science, of religion, or even of an ed. The world is all kinds of flexible and bends to fit us where we're at- such is the power of the human psyche. It's a bit of a mind trip then- does anyone ever really find a solution? All research on effective treatments are based on people- and on people treating people- and just because something works more often than not doesn't necessarily mean that thing is "right" and another method is "wrong"- only that, at that particular point in time, it bent to fit more people than it didn't.

Bleh. I'm out-thinking myself...

I like the Sagan quote, and I think it applies to all humans, scientist or not- if there's no "I might be wrong" then there is no opportunity for growth, for progress, for insight.

Anonymous said...

One of your Best Posts Ever, Carrie :) I really, really like the sound of Lilienfeld's lecture.

As a Biomedical Scientist and definite Empiricist, I love the idea of evidence based treatment - in theory. The caveat in terms of ED treatment, as far as I see it, is that there is a tendency to categorise people and supposed effective treatments by the disorder.

So, for example, a person can have a diagnosis of (e.g.) anorexia nervosa (AN), because they have lost a significant amount of weight for psychological rather than physical reasons and are somehow unable to cope with the idea of re-gaining the weight and the actual process of behavioural change to effect weight gain. Yet, evidence suggests that the treatment that is effective for more people than it is not (family based treatment = FBT) doesn't work for everyone. This may be due to the tools that are used to evaluate the efficacy of FBT in clinical trials, or something more specific to the person with AN and their families. But the problem is that if FBT doesn't work then the person with AN may be considered 'non-compliant', or their family may feel very guilty/hopeless for having 'failed' with their child.

Consequently, I like the idea of using the principles of a treatment paradigm while tailoring it to fit the needs of the patient. In AN, for example, there are data to suggest that the difficult-to-treat patients who have long-standing illness, have autism spectrum conditions, severe OCD, or certain traits that play a role in them becoming entrenched in the illness. If such traits could be identified pre-treatment (e.g. from parent recall of childhood temperament and behaviours), then it may be easier to guide effective treatment from the outset.

I will also add that a difficulty some researchers or practitioners have with regard to humbleness, is that they have built their careers around researching/practicing via a particular paradigm. If they are unable/unwilling to accept new evidence then for them this undermines their perceived credibility and identity.

I love the Sagan quote :)


Rock n Roll Carrie - what an amazing post and SO informative. The frustration with following the twitter feed is that I got tantalising glimpses of this speech but it even more exciting in the flesh, so to speak.

Thank you for your tweeting and thank you for this amazing blog post.


June Alexander said...

Carrie, thank you for this great blog on Lilienfeld's presentation. I now feel as though I were there. You are a gem. xx

Anonymous said...

While you may attribute the etiology of your own eating disorder to biology, I think you frequently underestimate the impact of sexual abuse and trauma on the development of eating disorders in your blog.

Unknown said...

Carrie, excellent synopsis and analysis. I was THERE and you've brought more clarity to the Keynote here!

Katie said...

Fabulous post Carrie, thank you! I was watching the twitter feed and feeling terribly jealous :) but Laura's post and this one goes a way towards satisfying the curiosity of those of us who couldn't be there.

By the way, that picture of you and the mechanical bull is adorable!

EricaBH said...

Fabulous, clear and funny - I enjoyed the twitter feed and being part of the action as it unfolded but was I the only one worrying that I couldn't always follow the 140 character code? I am learning to love twitter but it's sometimes hard work reading between the characters.

Just for further edification (and because I have a personal interest coupled with an occasional tendancy to pedantry!) I think Paul Revere was actually originally French; born in the tiny commune of Riocaud, SW France to la famille Rivoire - but that makes no odds to this speech, the import of which made my heart sing.

Thank you for this and I am really looking forward to hearing more.

stopbeingstupid said...

I really want to agree with what ExtraLongTail said - the trouble with (some) attempts to use evidence-based treatment is that they are too simplistic. They take the evidence that a certain treatment works for more people than another, then use it on someone on whom it does not work, even though there is evidence that FBT does not work on all anorexics and CBT does not work on all bulimics.

stopbeingstupid said...
This comment has been removed by the author.
Anonymous said...

I would have loved to attend ICED. I'd like to know how to get involved with eating disorder awareness--I have a pretty powerful story myself (who doesn't). But, more importantly, freeing myself from my story is of utmost importance. Having been a part of clinical trails raises the issue of research for me--now, I am the research (in a different topic). Research is important, learning how to apply it is a different ballgame.

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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