Based in Toronto and New York City

, Nancy Matsumoto is a writer and editor who covers sustainable agriculture, food, sake, arts and culture.

Archival posts from my former PsychologyToday.com blog, "Eating Disorders News”

Examining the Research-Practice Gap in Eating Disorders Treatment

I’ve been hearing a lot about what people are calling the “research-practice gap” in the treatment of eating disorders. Several things led me to write about it this week. One was a recent conversation I had with Marcia about the increasing emphasis on “manualized” forms of “evidence-based” treatment. 

The first buzzword refers to the process of researchers—usually psychiatrists and psychologists—conducting randomized controlled studies using a specific treatment method, then breaking down their results into step-by-step instructions (manuals) for clinicians to use on their own. The fact that these are developed with the guidance of “evidence-based” research, meaning studies that have been conducted under the rigorous circumstances of controlled clinical trials, gives manualized treatments the cachet that everyone—from pediatricians to parents —look for now. 

Most often these days, you hear the term “manualized” paired with “FBT,” Family Based Treatment, or its other name, “The Maudsley Method,” named after the London hospital where it was developed in the 1980s to treat adolescent anorexics. FBT was manualized by Drs. James Lock, MD, PhD, and Daniel le Grange, PhD (along with W. Stewart Agras, MD and Christpher Dare, MD) in 2002. 

Further multi-center controlled clinical trials by these doctors have resulted in a manualized FBT treatment for adolescent bulimia. Now the same researchers are at work on a manualized treatment for adolescent obesity, and there is also a version of the treatment geared toward parents, Help Your Teenager Beat an Eating Disorder. 

Manualization is a great help to professionals who have no special training in treating adolescents and adults with eating disorders, and (with the edition geared toward mass audiences) now an aid for parents, too. Yet what I’ve been hearing for some time now are cautionary murmurs from those clinicians on the front lines of eating disorders treatment: They’re concerned that the emphasis on evidence-based treatment is giving short-shrift to the clinical wisdom of eating disorders specialists--doctors, therapists and nutritionists-- who have spent years helping patients get better. 

Here are a few examples of the cautionary voices: 

• Psychologists Margo Maine, Douglas Bunnell and Beth Hartman McGilley have put together a book called Treatment of Eating Disorders: Bridging the Research Practice Gap. They note that while professional literature on the topic of eating disorders has mushroomed in the past 30 years, it is mainly research based, and leaves out the voice of the seasoned clinician. The authors try to remedy that gap in their book, with essays from expert clinicians on topics such as diagnosis, weight, nutrition and medical and psychiatric management.

• In a largely positive review of Drs. Le Grange and Lock’s book, Treating Bulimia in Adolescents: A Family-Based Approach, reviewer Pierre-Olivier Nadeau, MD, writing in the Journal of Canadian Academic Child and Adolescent Psychiatry, sounded a note of caution as well. “…. as is often the case when a new evidence-based treatment is developed, there are risks that other valuable treatments that do not have the same level of evidence will not be considered.” Nadeau notes that the authors acknowledge their manualized treatment might not be appropriate or effective for all cases, which means that “the availability of other types of treatment (e.g. individual therapy, group therapy, intensive treatments) will still remain important for some patients.”

• In a recent article in the International Journal of Eating Disorders, two giants in the field, Michael Strober, PhD at UCLA and Craig Johnson, PhD of the Eating Recovery Center of Denver, who have spent their careers straddling the worlds of both research and patient care, made the case for an integration of “pragmatic strategies supported by clinical research and experience.” 

Drs. Strober and Johnson noted three “worrisome trends:” 1) That “many therapists apparently see no place for the sort of clinical wisdom that can never be manualized; 2) That the emphasis evidence-based findings is “drawing attention away from more broad-based training experiences, “and 3) That “therapists who will one day encounter very ill patients are not being prepared adequately for taking on the many complex predicaments they will face.” 

These various responses to the research-practice gap give you a sense of just how murky and difficult treating eating disorders can be. Sometimes you need more than a step-by-step manual, no matter how rigorously arrived at, to help guide you. They are also an argument not to marginalize the pediatricians, psychotherapists, and nutritionists who have seen enough eating disorder patients to be able to have a feel for what the right treatment for each particular patient is. They are a plea for a more ecumenical approach to treating eating disorders, an approach that embraces different treatment methods and real-life expertise, to keep the focus on improving the health and lives of patients.

As always, we encourage readers to seek out professionals who specialize in treating eating disorders, which are highly complex, ever-mutating disorders that require both an up-to-date knowledge of the latest research and treatment techniques and a reserve of accumulated clinical wisdom.

 

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