Cheap and cheerful—Can cybertherapy be compassionate too?: Commentary on fairburn & wilson and Bauer & Moessner
Article first published online: 9 MAY 2013
Copyright © 2013 Wiley Periodicals, Inc.
International Journal of Eating Disorders
Special Issue: Transformational Science, Transformational Practice: A Special Issue Dedicated to Michael Strober, Editor-In-Chief from 1983 to 2012.
Volume 46, Issue 5, pages 522–524, July 2013
How to Cite
Ringwood, S. (2013), Cheap and cheerful—Can cybertherapy be compassionate too?: Commentary on fairburn & wilson and Bauer & Moessner. Int. J. Eat. Disord., 46: 522–524. doi: 10.1002/eat.22123
- Issue published online: 9 MAY 2013
- Article first published online: 9 MAY 2013
- Manuscript Accepted: 16 JAN 2013
Technology is a growing and increasingly routine part of all our lives. The first text message was sent on December 3, 1992. It said, “Merry Christmas.” In the twenty years since, we now send 200,000 texts a second across the globe. Google became a verb in 2003, and the web is the first place that young people go for any information, including on health matters. They are searching online before they speak to their parents, their friends, their teachers, and certainly before they think of seeing their doctor. Being part of a social network no longer means spending time sitting down with friends and family enjoying activities together. It's a virtual world, not just a physical one.
Eating disorders are increasingly recognized as a global health issue. Treatment is expensive (whether funded by Governments, insurance companies, or individuals); can be lengthy; and outcomes are uncertain at best. Is it any surprise then that consumers and clinicians are seeking web-based and technological solutions to shortfall in therapy and treatment? In our time of economic restraint and austerity, it's certainly cheap, but can it be cheerful and compassionate too?
In 2012 at Beat, we had contact with 240,000 people affected by eating disorders. They called our help-lines, came to support groups or accessed our message boards and web forums. For families, the top concern was “when will my child get better?” followed by “how do we get treatment that we know will work?”
We stay informed, up to date and up to speed on the latest research. We are committed to bringing the science to families understanding of eating disorders. We still can't answer those questions. No one can. We say something about the percentage of people who recover over an average length of time. We can talk about the evidence base for effective treatment and what seems to work some of the time for some people.
Our hearts break along with the families' as we listen to them struggle with that balanced, carefully selected information about treatment and recovery. We know how important it is to convey hopefulness, and it feels so inadequate a response to the frightening, overwhelming situation they find themselves in. How long before we have those answers, and is technology going to provide the breakthrough?
Even in countries with well developed, funded, and advanced health care systems, expertise in treating eating disorders is too variably distributed. It tends to be concentrated in centers of excellence, of which there are too few to meet all the demands for their help. The global situation is one of terrifying gaps in skills, expertise, and access to effective care.
Most people with eating disorders do not get expert, specialized help unless (or until) they are very ill indeed and at serious medical risk. Not infrequently, they and their families have to battle both the illness and the system to get that help, or go it alone and risk the consequences. In the United Kingdom, even with publically funded health care free at the point of access, patients can have to prove that they have “failed” at less intensive, community-based treatment before becoming eligible to receive specialist help. For example, families are told that a body mass index of 15 is “not low enough” to warrant admission to hospital. They face an agonizing time of watching their child become even more ill while waiting for the doors to help to open for them. More frightening still is being told that since treatment “didn't work last time,” publically funded health care will no longer be provided; such are the pressures to control health care costs.
Surely, if the Internet has a solution to any of these dilemmas, we must grab it with both hands. Effective treatment, readily available in our homes, anywhere in the world, at very low cost to health care providers—is it too good to be true?
The reviews by Fairburn and Wilson, and Bauer and Moessner, set out clearly the potential benefits of developing technological platforms to augment present capacities for care delivery. Such platforms could both be used by health consumers to access effective treatments as well as by health professionals so as to train sufficient clinicians to provide treatment. There is much to recommend in both these propositions. Treatment for eating disorders needs to move with the times; making full use of the strengths, qualities and opportunities afforded by the internet have to be part of the future. We all need to get up to speed.
Both sets of authors are equally clear that there are gaps and deficits in the use of technology, neither advocate it as the one and only solution to providing effective treatment and care, and there is much to be optimistic about; and yet, doubts remain. For instance, there will be necessary compromises with uncertain impacts on patients: will the quality of care be unacceptably diluted if we expand its reach? Or is it nonetheless preferable to reach the millions of people globally who need treatment and care, even with what could be a lower “dose”? Fairburn and Wilson1 propose that “what is needed are effective treatments that can be used with the broadest range of patients.” Their solution is a combination of a transdiagnostic approach with internet-based delivery. Leaving aside the transdiagnostics, Bauer and Moessner2 raise questions about just how broad that reach has to be to make a real impact through prevention and early intervention. If we are talking about the lowest dose, lowest cost treatment, then how broad should the coverage be? Is it like an inoculation that a public health system would provide? What would the vaccine be?—to take that analogy a bit further? When should it be administered, and how long would its protective effects last? We don't know.
For Fairburn and Wilson, it is also a matter of overcoming the lack of skilled, trained therapists who can administer evidence-based treatments. They envision the internet being harnessed to make that training available more readily and more affordably everywhere. It's also part of ensuring that research into effective treatment is translated into practice as soon as possible, but there is often a long march between basic science discoveries and effective interventions. Another type of challenging call we get to our help-lines follow rapidly on from any media coverage about research findings. Parents call wanting to know where they can get the neuroimaging done that will prove if their child has anorexia nervosa, for example. We have to explain that it is still being investigated in research studies, and still several steps removed from clinical practice.
Picking up the speed on implementation has to be part of the solution. We need to get the eating disorders expertise out of the ivory towers of academia and into the whole of the health care system. We need to get it out beyond the specialist treatment centres, too—not to remove this expertise, but to share it more effectively—and the internet can certainly be a platform that supports that.
The challenge of implementation is not only in the need to scale up, speed up, and make accessible the effective treatments derived from research evidence. It is also about ensuring that the treatment remains effective when implemented in real world practice, once beyond the controlled and optimized setting of the research protocol. This is where Fairburn and Wilson make a strong point- that currently too many clinicians are “trained” by attending short programs or workshops that do not necessarily measure or judge their abilities to deliver the therapies as described. If both the training, and to some extent the therapies were delivered in standardized, internet provided, same-every-time ways, therapies with proven efficacy in clinical trials would stand the best chance of also being effective when translated into routine clinical care.
Emeritus Professor Robert Palmer (Palmer R, personal communication) suggests that one approach could be to stop framing eating disorders as such a specialist condition, only able to be treated by the experienced few. He feels that message risks making competent clinicians doubt their skills, clinicians who are already likely alarmed by the prospect of dealing with such tricky patients and a scary, recalcitrant illness. This view is upheld by Jones, Saeidi, and Morgan's brief report “Knowledge and Attitudes of Psychiatrists Towards Eating Disorders” (2013)3 which shows that while 60.5% respondents were confident in their ability to diagnose an eating disorder, only 14.9% were confident in their ability to manage these conditions in their current practice. Professor Palmer's view is that if eating disorders were seen more as part of the everyday, run of the mill work of mental health treatment—serious, but ordinary too—then more people would get treatment more readily. After all, it works for acute psychosis.
But is it enough to have lots of people able to do some simple, basic early interventions? Do we know whether all eating disorders can be arrested in their development with early intervention? In this new technologically trained world what will happen to the person who doesn't respond to the low dose? Where do they go, how do they get the more intensive, more expert care?
Given how many people right now have serious, enduring, untreated eating disorders, perhaps applying the Utilitarian philosophic principle of the greatest good to the greatest number is better than almost all going to a few—but is it a strategy? Can technology provide the greatest good, or are we settling for too little?
The case is not fully made that technology and technology alone is more effective than or a significant improvement to therapy as conventionally delivered. What is not yet demonstrated is how, and where and in what circumstances this new mode of therapy is as or more effective. The concern would be that in the understandable drive to get something out to as many people as possible, the quality will suffer: the “something” offered is not potent enough to make a meaningful or adequate difference in treating these serious, challenging disorders.
The internet undoubtedly has its role and value in our lives. It has transformed lay people's access to health information and knowledge. It can open opportunities on a scale and at a rate that is expanding exponentially. The papers by Fairburn and Wilson, and of Bauer and Moessner, clearly show the importance of clinicians and researchers in embracing technology and harnessing it for therapeutic use. The ways in which technology can add value and utility need to be maximized—as an adjunct to face-to-face work; to provide psycho-education to patients and their families; to support people on waitlists for more intensive treatment; to sustain recovery following discharge—all of these areas are certainly worthy of development and of improving the evidence base for their effectiveness.
The glaring gap that is not covered by either of these elegantly presented papers is the human contact. Where is the therapeutic alliance, who is holding the hope, and sharing the sorrow? Where is the compassion?
Eating disorders thrive on secrecy and isolation. People affected find it increasingly difficult to stay connected with their significant others. Their human contact shuts down. The world is experienced as a hostile, threatening, and cold and they feel they deserve its scorn and the pain it causes them. “I'm not worth it” is a comment we hear so often from callers to our help-lines.
“Cheap and cheerful” is a British idiom. It describes something not expected to be of durable quality; something disposable; or a lesser substitute for an unaffordable or unattainable valued item. People make do with something cheap and cheerful. Few would choose it if the higher quality, valued item were an option they could afford. The concern is that internet-based therapy could become such an item, always second best, a make-do solution.
Beat spends a lot of time listening to people who have recovered from their eating disorder, learning from their experiences and sharing their insights with others still on the rocky path to health and well-being. There is a strong, consistent, and common thread that runs through their accounts. It can be summarized as “thank goodness someone reached in and pulled me out of that deep pit”. Someone. Someone who cared enough. Someone who loved enough, was brave enough, refused to listen to my protests enough. Someone who believed I could get better when I couldn't believe it myself. A parent, a friend, a teacher, a therapist. Someone.
The UK Government is soon to introduce a new quality measure across the publically funded National Health Service—the Friends and Family Test. Patients and staff will be asked whether they would recommend the services they have received or are employed by to a loved one. The results will be required to be published by hospitals, general practitioner practices, and community-based services. It is part of the commitment to “compassion in practice.” Would internet-based services pass the Friends and Family Test by being recommended to a loved one? As these technologies are evaluated by scientists and practitioners, we should also be listening to the patients' voices.
Compassion is ability to empathize with the suffering of another and to be motivated to alleviate it. The internet has many qualities, but I have yet to hear anyone say “thank goodness the internet cared enough for me.”