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2012 ICED Thoughts, Part One

Posted May 08 2012 11:23pm
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 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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