Pride and Prejudice

“It is never too late to give up your prejudices…No way of thinking or doing, however ancient, can be trusted without proof. What everybody echoes or in silence passes by as true today may turn out to be falsehood tomorrow, mere smoke of opinion.”

Henry David Thoreau, Walden

Last weekend, I attended the annual National Eating Disorders Association conference in New York City. It was a fantastic conference and an exhilarating experience, a whirlwind of thinking and conversing and listening and networking.

That said, I attended a few lectures that made me cringe and perhaps set the field back a few years. One well-known psychologist and author stated in her lecture that there’s a false dichotomy between research and practice, because all clinicians are, ipso facto, researchers. She went on to explain to the clinicians in the room that that if you work with eating disorder patients and you contemplate eating disorder issues, then you are a researcher.

I think, therefore I am…a researcher?

And therein lies the rub. Working with eating disorder patients and thinking about them does not make you a researcher anymore than watching MSNBC and contemplating the mid-term election makes you a political scientist.

Historically, a major problem within the field of eating disorders is that etiological theories were formed, and treatment approaches created, based upon clinicians’ casual observation and reflection. Hilde Bruch, MD, who wrote the highly influential book The Golden Cage (1978), based her theories on her observation and treatment of the anorexic patients in her practice. Bruch concluded that anorexia nervosa occurs almost exclusively in upper-class white families (because those were the families, residing in her primarily Caucasian neighborhood, who could afford to enter treatment with her), that dysfunctional patterns of family interaction are key in the etiology of anorexia nervosa (because she observed strained and tense relationships between her severely ill patients and their worried parents) and that anorexia represents a misguided attempt at forming an identity and asserting some control over an otherwise uncontrollable life (based upon the self-reports of malnourished patients suffering from a brain disease).

This book was immensely popular amongst clinicians and the general public, as it was the first book to attempt to explain anorexia nervosa, and these theories became professional dogma. Bruch’s ideas spread like wildfire, and it would be many years before scientific research would be published to counter her claims. And to this day, more than three decades later, many clinicians, anorexics, and their families still hold these beliefs.

We are, in general, resistant to change. People have a very hard time letting go of long-held beliefs, which may explain why societal change tends to happen incrementally over generations. Many clinicians have so much pride in the work they have done in the past, and so much prejudice against new ideas which are diametrically opposed to their own, that they vigorously defend the theories they have held forever even when all reliable evidence points to the contrary. They seek to assimilate new information into their preexisting beliefs (for example, a racist person may boast about having one black friend, claiming that his buddy is “not like most black people”) rather than abandoning their old beliefs once it becomes clear that they are flawed. To quote the 17th century philosopher John Locke: “New opinions are always suspected, and usually opposed, without any other reason but because they are not already common.”

It is essential, therefore, that the most recent scientific research on the etiology and effective treatment of eating disorders is featured prominently and unapologetically at local, national, and global events aimed professionals, patients, and families in the eating disorder world. The new message cannot be muted or diluted with antiquated theories or treatments under the politically-correct assumption that all ideas are equally valid. As it is, big-name wealthy treatment centers get the most publicity, most likely because of their massive donations to eating disorder organizations who feature them prominently in exhibit halls at conferences. People are so easily swayed by catch phrases and neat giveaways and glossy brochures featuring impossibly happy eating disordered teenagers riding horses and finger painting. But these centers do not necessarily offer the most effective treatments. If we want our field to make progress, if we truly want to save more lives and rescue more sufferers from the agony of this illness, money cannot trump science.

One of the most promising statements I heard all weekend was this, from a psychologist who is the director of an eating disorders treatment program:

“It is no longer acceptable, in 2010, for clinicians to practice a certain way simply because they have been practicing that way for years.”

My friend Carrie Arnold and I gave a standing ovation to that one and clapped until our hands hurt.

We invite you to join us in doing the same.

13 Replies to “Pride and Prejudice”

  1. It was great to meet you at NEDA and interesting, if also a bit overwhelming, to see the differences in cultures between the US and UK treatment world.

  2. Hey, I’ve worked with an eating disordered person (my daughter) and I think a lot about EDs…I guess I’m a researcher too! Move over, Dr. Kaye!!

    I think I was at the same session. It was billed as a lecture about bridging the gap between research and treatment…specifically, in my mind, I was imagining how you take Walter Kaye’s research on things like serotonin imbalances, abnormal dopamine reactions, etc, and find treatment practices that address these physiological problems. WRONG!

    “Science” in this lecture consisted of compilations of patient surveys. Surveys will tell you what this particular group of people who used your product thought of it, and may guide you in ways to improve your product. This is a good marketing strategy, but it is not science. Her self-selected demographic tended to be 30-ish, long-term anorexics who had been in residential treatment 3 or 4 times prior to arriving at her facility. This director may have been able to better serve this particular clientele by analyzing the results of her survey, but to extrapolate this data to the ED population at large was a pretty breathtaking jump.


    Great, great post, Dr. Ravin, and a pleasure to meet you at NEDA!

  3. I agree wholeheartedly. My daughter received the typical treatment with a therapist who just let her talk about anything and told us to stop trying to control her in any way. Two years later and nearly twenty pounds lighter, we switched therapists. Of course there were many other negative effects from this therapist too such as creating a significant rift between my child and me. I am saddened and surprised by the many “experts” I interviewed who still hold tightly to these theories and are truly prejudiced against FBT aka Maudsley. One ACT therapist even told me I shouldn’t try it, because it isn’t allowing her the control she needs . . . so I should let her starve herself until she needs to be hospitalized or worse? If our children can’t feed themselves, why wouldn’t we step up and help them? Frustrating! It’s absolutely awful for the people who are trying to seek help. I wish I knew what I do now when I first looked for a therapist and that “researched-based quality care” was the norm not the needle in the haystack! Thank you for your insightful post; I consistently find them valuable!

  4. There is a social schizophrenia around to have the looks of that one are expected to have and media plays a key role to add spice to this. If you have an eating disorder and are looking for an eating disorder treatment center you can at least rest assured in knowing that there are many options available to you. By using the resources that are available to you you should be able to easily find a decent eating disorder treatment center near you.

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