 So, welcome to this event of Russian language event. If you might know, we have 40 events that we are planning to do, and they are organized by the U.S. Official Psychology, and the OV, N.K. Hancock, and Ben, and the Lancet Psychology. So we're going to use it, we will, again, on the date after morning live, as we used to hear. This is a really event to connect the general public to what's happening in policy research in general. So as much as it's a panel here, and I really love the very much in this, because it doesn't matter what you have to say, what we have to say. I'm just going to appeal to the issues people are traveling, who they expect in the fire lab. So if people go off, let's go on and talk about it. The toilets are outside the window on the right. We have 3.5 if you need to connect. The name of the network is used, I guess, and as we say, it should be that way. If you want to create the document, you can use the hashtag, I guess you can. And then after this, so thanks to Naples, just outside of here, we're going back out today. So if you want to stick around, I see questions in the chat, we hope a lot of you will join us. So without further ado, we're going to introduce the chair of this panel, Dr. Marcia Naples, the chair of the Secretary of the United States of America, the mayor of London, and she will speak with us, if you want to talk to us about this course, we're going to speak with us today. I'm going to go through the chair, I'm going to go through the chair of the Secretary of the United States of America, the mayor of London, and she will speak with us today. Thank you very much. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. And welcome. I get to be David Dimpleby, for this event on eating disorders, which I'm delighted, but I think there have been a number of these sort of events, but to have one on eating disorders really does bring together a fantastic opportunity to different perspectives from the clinical, personal policy and research on a hugely important topic that we know is certainly not going away in a hurry. We have exceptional panel speakers, and hopefully we're going to cover through both what they say and the questions from the floor, the full range of eating disorders. The format today is that I'm going to invite each of the speakers to say a few words in response to a specific question, and then we have some questions that have already been sent in, and we will invite questions from yourselves and from the people who we are live streaming to. So hopefully we'll have a, not overly heated, but heated debate on topics of importance. So I'm going to start by inviting Dr. Tarnak Professor, Tim Kendall, to respond to my question about policy. Tim Kendall is the NHS England's National Clinical Director for Mental Health. He's been director of the National Collaborating Centre for Mental Health at the Royal College of Psychiatrists for 15 years, and visiting professor at UCL. He was chair of the Nice Guideline Committee for Eating Disorders, which is where I first came in after Tim. Tim also works as a consultant psychiatrist for homeless people in Sheffield, and he chaired the very first Nice Guideline on Schizophrenia in 2002. So our question to you, Tim, is what's been done at a policy level to improve eating disorder services? Okay, thank you, Dasha. For those who aren't aware, about three and a bit years ago, NHS England produced a five-year-forward view for mental health, and a very important part of that was work around children, which involved significant investment, about 1.4 billion over a period of five years. One major piece of work in that was the introduction of a new eating disorder programme for under 18-year-olds. What that did was to introduce, at the very first time in mental health, a waiting time standard. So we promised that children, young people, would be able to access nice concordant care, and that they would be able to do so within four weeks of referral, if it was routine, and within one week, if it was urgent. And we promised that by the April of 2021 that we would be achieving that standard for 95% of children. I'm pleased to say we are reaching 80% of their children for both of those standards today. So that... I've visited some of these services, and I think thanks to those people who are running them, they are phenomenally different to anything I've seen before. So all good news now. In the adults here, we have nothing on eating disorders and the five-year forward view. The five-year forward view, I should say, was effectively co-produced with 20,000 people, professional service users, carers. So what they decided we should focus on in this particular instance didn't include eating disorders in adults. And I think it was a good case to say that if you're going to focus on anything, let's focus on children and young people first, because getting in there quickly matters. Now, what we have done for the long-term plan, which started this year, we've got £2.3 billion to invest per year working up to £2.3 billion over five years. So that £2.3 billion per year, probably the biggest increased investment in mental health services in history for the NHS. But else is that the biggest proportion of that will go into community mental health. Now, community mental health will include anything that you might think of as a serious or severe mental health problem that will include eating disorders for adults as well as personality disorder, people with psychoses, people with complex chronic mental health problems, and people who've got complex comorbidities. Now, what we'll do with that over the next two years is we're investing in different pilots around the country to try and work out how we can achieve a four-week waiting time for adults, not just in eating disorders but across the whole community mental health. Now, some of those pilots will be specifically eating disorder services, and they will be expected to run a waiting time of four weeks. The end of that period, we will be able to then say what we can realistically achieve with them. Now, alongside that, we've also, we're picking up all the currently NHS England Specialist Commission beds for eating disorders. There's about 402 of them. They cost 82 million. We've done some pilots, one of which I've been to recently in West Yorkshire, where we've given those beds back to a lead provider, in this case, up in West Yorkshire, the leads, your lead provider has taken the money and then they've used the beds. They've shortened the length of stay, they've shut some of the beds, and they've introduced care pathways in the community. So that will go on alongside the additional investment. So, I mean, there are lots of other things that we're doing. We're investing in new ways of working, like around free and so on. And really anything that really starts to look like we could do something with it, we're very keen to look at and see if we can organize it in the program. But our aim, I need to say, is that we reach the same level of quality and access to services for adults and lead providers as we have for children. But we're not there yet. Thank you. I'm sure there's lots of burning questions. I'm going to ask you to hold your questions for the moment, but I think it's best to say this is the last five years it's been the most rapid expansion of development and eating services that you've seen. It's the biggest expansion in eating disorders, but also in huge areas of mental health, early intervention in psychosis, crisis teams and so on. Lots and lots of different developments and that has now reached a much higher level. You cannot believe how busy we are in mental health. Mental health is now probably the top priority for NHS England. And we have the biggest team for implementation and transformation. I don't want to give the impression that we have arrived, we have not. We've just started. I guarantee that the money that we've got in the long-term plan will be ring fence for the next 10 years. So the money that we hand to CCGs will be spent in mental health. It's also the envy of other countries having talked about this in various international eating service conferences. What's happening here. So let's hope we can set a blueprint for the rest of the world to see some of this. Thank you. Moving now to James. So James has experienced a major eating disorder from the age of 16 and although now well into recovery he faced many barriers and a six-year wait to access specialist treatment. He now works as a volunteer to develop eating disorder services, campaigns for changes in policy and awareness alongside studying psychology and education at the University of Cambridge where he researches understandings of the concept of resilience. Is that enough? I've met James in many expert reference groups like convocations, approaches groups, cross-party parliamentary groups. You name it, James is everywhere being an advocate for service users. James, our question for you is how do you see access to eating disorder services? Okay, so hi everyone. I'm really glad that Tim took more than a few words because I was really nervous when it was just a few words to explain access to eating disorder services. I could summarise it, it's very difficult and it has been very difficult. I'm acutely aware that I'm representing sort of lived experience on the panel and just want to reinforce that I'm only going to talk about my experience and it is just my experience. It's not generalisable to everybody but hopefully there are some points that I can pull out from what has been this sort of traumatic and long journey with lots of twists and turns that are helpful because it could be really easy to go through this sort of 15 years, sort of 14-15 years of eating disorder that I've experienced and portray it as a catalogue of awful experiences which it generally has been but I want to be able to say something that is useful that maybe I could have benefited from and even though it is just my experience, hopefully those points those general points resonate with others as well and I don't think personally from people that I know and seeing lots of people here from Twitter and this kind of stuff, I know that they're not uncommon experiences so some of the things from my the whistle stop highlights of life with eating disorders that relate to accessing services, I think going up to the beginning I think at the onset barriers to accessing services were a lack of recognition of what were the signs of eating disorders in the first place and for me the disorder eating was tangled up with other symptoms around OCD and body image and the eating disorder didn't present at first and the mental health problems occurred in school in the first place and people around me didn't know that it was a mental health problem they thought it was bad behaviour and then later on I went into services and developed shifted from 40 to small fit behaviours towards food, weight and shape and the people even within the services didn't really recognise what was happening so if the people in services didn't have the knowledge that anorexia could happen to a young boy as well then I think no wonder people in the public don't really understand that I think that part of things has improved with awareness campaigns and I don't think I would have had quite the same experience now if it happened again as many as 15 years ago but I think that that is the first part in terms of access is spotting it in the first place another part would be something that a lot of people might relate to about barriers to access in terms of weight in terms of physical health status so I feel like I've experienced it from both sides having had anorexia and bulimia still living with bulimia now a very long time I couldn't access what was available because I was deemed to be too underweight so I didn't have the cognitive capacity to engage with CBT which was the only thing that was on offer in my area I don't think that would happen now because there's evidence and research which suggests otherwise but at the time I was told that you have to gain weight in order to access therapy and I had to do that on my own well if I could do that bit on my own then I wouldn't have needed it in the first place so it was that at that point it was all about physical health management so I did have my life saved multiple multiple times in A&E and had my potassium pumped in all this kind of stuff and sent away to no specialists general support that I felt didn't really address me as a person the other side of it has been when my weight has been too high to access treatment which has been the case more recently and I have lived with severe bulimia for a very long time and I still have it to this day and there was a long time where I didn't want to access services at all because I didn't really have much hope which I think is how I see accessing services I was refused the first two times when I tried to access services in Cambridge and I was told that I was too medically stable to access the services even though I was experiencing sort of 4 hours of binging and purging behavior every day 20 plus hours of exercise per week a full time job in the maintenance of the eating disorder and I've worked really hard to be medically stable to avoid immediate cardiac arrest this kind of thing and I was not going to give that up in order to access services I finally did get into services in Cambridge and it happened by going to a conference and speaking about not being able to get services in Cambridge the technical leader of the service was in the audience she came up to me afterwards and said I think if you were a furth now you might get in it's sort of like an audition but I really have to worry about the people who can't speak at conferences and it shouldn't have to be a fight to get access to services in the first place and I'm privileged to have the voice that I do and I said to her I will take it to the media again if I don't but that really shouldn't be the way and I don't know where I get my confidence in terms of that but I'm lucky for it and not everyone has that and I did not have it for a lot of the journey other sort of barriers to accessing services have been a whole set of assumptions based on the lack of knowledge from professionals I think some of them relate to being male a lot of the time I found that professionals were chasing other diagnoses because they couldn't just accept that I have anorexia as a boy diagnosed with multiple different things all of which I don't really accept now I think that there have been assumptions around being sort of middle class and having a well to do family that I therefore practically have support which I did not and through no fault of my parents they were often no support assumptions about being intelligent that I understand about eating disorders and therefore I must be able to think my way out of them I've tried it and it doesn't work and I was a medical student at one point which I had to drop out of that was on my records every time I went into A&E you're a medical student you know what you're doing to yourself why are you doing it yes I knew exactly what I was doing to myself the potassium works but I was still doing it and that caused more distress because I knew exactly what was going on didn't make it easier I think a bit harder and sort of assumptions around anorexia and bulimia sort of that bulimia is not serious basically and that has been something that I've had to fight against I think there are unique sigmas around eating disorders which help lack of access to services just highlighting that with one example is being in a meeting working as a services representative where I was kind of undercover because I hadn't introduced myself and heard professionals saying things like I don't work with people with eating disorders they're manipulative these attitudes do still exist within services never mind in the public and I think that those things have to change and it's a matter of training and results for sure but there are so many barriers other barriers on top of barriers for example adding on gender or whether it's sort of diagnosed as not much support for like binge eating disorder or ethnicity or culture it becomes more and more of a fight and I think that that's just not really what you need you shouldn't have to fight for it when you're already really fighting a couple more points and taking the privilege of being the sort of lived experience person that I can't condense 15 years into two minutes but I think it really matters actually not just about access to services I don't think it's good enough to tick a box saying you've met for weeks I think what matters as well is what happens when you're in the service it's all very good to be able to get into services to access support but what is that support is it of good quality, is it what you want how is that support collaborative because a lot of my experience in services was confrontational I got into the services but it was you will stop the behaviour or X, Y and Z will happen it sort of didn't really form an alliance didn't really help me to get better so what I had eventually was a bit too little too late and we didn't have the relationship to make much progress so I really think that's important last couple of points there'll be a lot of talk I think tonight about early intervention and I just want to highlight that the vast majority of people with eating disorders will never ever have an early intervention because that time has gone and I think that it's really important to remember what we offer to those people as well and kind of the word intervention I didn't really want intervention intervention seems very invasive I wanted somebody to care and I wanted help I didn't want intervention when help did come it was intervention that was forced if you will go to hospital you will be sectioned if you don't do this and I think that the nature of the help is really important I think it should be help and care not necessarily forced intervention services need to meet you where you're at rather than imposing things a lot of people don't necessarily want to change there needs to be a space for those people as well to be in a service without being intervened with and then being held by a service and I want care when I go to the GP they say you're the expert you know blah blah blah you want all these committees I saw your name on this guideline and I know that I probably know more than the GP but I still want them to care I'm a human I think every single moment of help seeking in light of that think about early intervention every single moment of help seeking is an opportunity for early intervention in that moment eating disorders have a long duration they're complex, they involve relapse they're up and down and I think that every time someone comes forward to help whatever stays on their journey they're equally valid of having early intervention provided the picture of their illness is now and I think that very often when I've gone to get help the responses that I've had have been so unhelpful in terms of being told for example Bellini is just attention seeking or just having sort of real misinformed opinions or you're not sick enough to access that service and the end product is that you feel unreal and that your problem is not worthy of support you need help again and that for me is really anti-hypopatic it's doing harm I think when people come forward to help it's a super vulnerable moment what happens in that point is really important and it's a miracle when people come forward for support because they might have heard all these stories but it's so terrible anybody watching this and me saying it will be really really awful for me I would still say go and get help and if you don't get it it's not your fault you really have to think about what happens in those key moments and this thing of doing no harm it is not harm free to go to the GP and be sent away with no validation it is not harm free to stay on away from this that is not a harm free place to be it's not harm free to move area to get treatment it's not harm free to be incentivised to lose weight to access the service and it's not harm free to be scared and to get some better and never offered a positive reason to get better I never had a conversation about what do you want your life to be like it was all about you don't want to do this because it's awful you know so why was I hoping that so access really my summary for the whole thing is that I don't think when I think of access I think of going through security at the airport to access that area or sort of climbing like you're accessing the highest peak I don't even think it should be access I think services should be offered not access it shouldn't be a fight to get into services and I think that it should be that you go for support when it's offered or somebody identifies that you have a problem even if you didn't go for help because they're knowledgeable about it they support the science for you and they encourage you so I think that I would just reshape the idea the way we think about accessing services because now it is a fight what can we do to remove as many barriers as possible it comes from research it comes from training it comes from resorting and other people we have to talk about that a lot better than me but if we manage to do that hopefully people won't have quite the same experience as I had thank you summarising 16 years in a few minutes but also I think the money is all how it can be valuable personal experiences to what we do and what we learn and how we do things thank you I realise it's a new story but there's so many important messages and we just said thank you very much so moving now to research which you mentioned a few times our next guest is Dr Francesca Salmi she's an epidemiologist in the UCL vision of psychiatry her research interest is on the application of causal inference methods to understand what causes eating disorders across the life of course she's also interested in studying causes and the sort of eating in the general population Francesca currently holds a welcome trust so a Henry Welkin Fellowship study where the inflammation contributes to increasing a person's risk to the bad meeting disorder Francesca your question is what is the state of eating disorders research so it's a great progression I think I might have thought about some of the good things like being able to do research in the field of eating disorders that she's currently facing to be honest the research is very suggesting that in the last few years we've been increasing the rate of eating disorders in the life of the staff we have a pre-boss a gene-wide association that has genetics so if I'm writing a book and studying the genetics I'm working on it so there's a lot of new variables so there's a lot of research around that but there's also challenges and one of the biggest challenges for eating disorders research in terms of the quantity of the output that the user lacks behind a lot of the other south conditions and one reason for this is that there's a lot of funding that gets even to eating disorder research so that's been many of you have shown that the quantity of mental health funding that goes through all different mental solutions in eating disorders it's not just eating disorders it's another process that gets out of the bottom in terms of the amount of research that's out of the bottom so I think in the future what we try to quantify is the potential of all the UK mental health funding that gets even to eating disorders it was 0.4% so that amount was 7% for schizophrenia so for the ration it was about 5% for schizophrenia and to almost 2% for autism so anyway what I'm going to do for the question is if you want to say why eat bananas but when you compare the bananas to eating disorders and schizophrenia in your case and there are similar countries so when you try to compute their amount and what you spend per person eating disorder if you pay it calculate that it's about 50p per person eating disorder which is shocking in my opinion and if you compare it with autism so we compare the politicians that have seen about bananas that's about 4 pounds which is still probably below and 61 pounds or 63 which is almost highly funded and not to mention the woman's health condition with 50p for eating which is shocking so for example this we try to look at how this translates in number half what's it produced in terms of people's needs and we look at how many people's needs and how much that's here and it's about 5% for all the people who have schizophrenia and for all people who are starved or on more days so to compare it again so if there is less research it means that we know less and we just have James talking about how the findings that change is ability to access certain services and we need research to improve access to eating disorder services and something else that seems to happen with eating disorder receptors and it's not eating disorder receptors in my opinion it's like they seem to get published less in the most important genres about psychiatry so another thing that we look at is how many people are on eating disorder published in the most popular psychiatry genres and again it's shocking a lot and you think if your people papers are all published and you expect that after papers published in these genres that we look at a proportion of your own numbers and the proportion of eating disorder papers published in this beginning by psychiatry genres was all over the lab and it seems to be certain inequality towards eating disorder research and the interaction so it's a bit of a cycle where there's less funding who produce less it gets into the more niche the more specialistic genres fewer people see our research and then it gets salient that eating disorders are not that important if it's maybe genres with a great disorder it's not seeing this research we get that something but also in terms of so I work with a lot of survey in general population data and it's very hard to find people on some of its service include data on eating disorder and I think there was an example of the last adult psychiatry on eating disorder in 2015 which should include a general eating disorder and that's a massive opportunity to calculate how many people have disorder eating disorder in the population in what's the level of need in the population but we know that eating disorders are very serious when epidemiologically we look at the strict definitions of eating disorders about 5% of the population will have an eating disorder and we start to look at the substantial of eating disorder that's a very large number in the population and for the private of mortality we know that recovery rates could be better so we do need research and it's a different sort of everyone is about I think it's the HVMI that's a people on miscellaneous and so on so I think in the sense of basic we need not only to do new therapeutic approaches so those evaluating the happiness prevent safe measures, because we pose something to deal with the device prevention strategies. We need to know what happens in the long term to be completely disordered, even after the recovery, and we need to know what needs to be done, so we can do some sort of this influence in terms of what's the reaction, of course, that can be from research still, but also, you know, there's a big difference in the amount of research that we have done, so they can use some direction, of course, versus when there was an injury, so we don't know more about our accident, we don't know about the injury, so we don't need to know more about the injuries that were across the sector. So, before this is achieved, and for people who are active people, we need to stop considering eating disorders as a niche specialty within psychiatry, in a higher frequency, with other psychiatric conditions, and so we can have a smaller injury, such as eating disorder. Okay, I'll give time for questions from the audience. So, our next speaker is Dr. Karina Allen. Karina is a senior clinical psychologist at the South London University NHS Foundation Trust, eating disorder service, and a visitor for senior lecturers at King's College level. Her current work is focused on a successful role out of FREED, you had Tim mention earlier. FREED stands for the first episode of rapid early intervention for eating disorders within the UK and beyond. She's been supported in this work by an NHS Innovation Accelerator Foundation. Thank you very much. Oh, yes, I have a question for you. How can we improve outcomes of eating disorders? Thank you. And I think I really want to start my answer by acknowledging that there is no single answer to that question, and all of the points raised this evening are going to be part of how we improve outcomes. We'll slope to this input with everybody in this room. There are researches, clinicians, sociability and experience, policy-related divinations in London, but also if all of you out there are interested in some type, where the community sees these disorders, all of these needs come together after the drawing on the different components of experience and expertise to bring about the changes that we need. We know at the moment, certainly for adults with eating disorders, outcomes are only one of the least successful at best. And the stability, depressing position at the end, despite decades of efforts to improve treatment outcomes and improve the treatments that we have available for our eating disorders. The situation for children and adults that are more positive and get good outcomes from found invasive infections. But there is much more to be done to improve the effectiveness of the treatments you have out and to better the treatments that tap into what we're clearly not able to achieve at the moment. As both Tim and James have already alluded to, I think one of the biggest areas that needs to change the greater and freed up of eating disorders is access. Again, we've had fantastic developments to talk with our residents. And then you know, self-proclaimed eating disorder services, vibrato diet at families, and you see it moving up quickly. But adults, it's still very, very difficult. Long-lacing times are standard, and many areas of the country services are only set up to see the most severe presentations or to provide a really unlimited support and certainly not for evidence-based treatments that are recommended and characterable guidelines. So one of the initiatives that our service has been working on over the last five years is freed. And as I mentioned this is the first episode of our third early intervention for eating disorders. And this was about across the water eating disorder service making this college one of them, very much a collaboration with young people and those with a lived experience. To provide a dedicated early intervention pathway for 16 to 25 girls who had eating disorder at less than three years duration. And this is only one subgroup for those in need of disorders and I absolutely acknowledge that. And we'll come back in a little while to the fact that we need to think beyond this group as well. But what free community trust is doing is providing rapid access to specialist care for this particular patient group. But also tailor the evidence-based treatments we have for the specific further mental needs of these young adult to the relative degrees of hospitalization disorder. And it's just a really straightforward thing. It's like being very proactive and flexible with how you try and engage with young people. We're often really nervous about coming to a specialist service. Being a little flexible with how we communicate so we'll send a text and send us any letters. We'll offer appointments at different times which is kind of crazy idea but not everyone can come in at 12 o'clock on Thursday. But we also do things that really try harder to involve families or it's appropriate to do so. It should stand at the underage team so often we drop off once a week for this 18-year mark. Prepare a lot of attention to the transition. So transitions out for child and adolescent services, out to school, into work and especially around university. Because this is an age group we're often moving between university and home. And it can often require a book from two services and really provide guidance on how we can do this safely and effectively rather than having patients really get lost between two different geographical areas. We talk more about these social media and identity formations which are relevant across the life span. We get on particularly relevant often with this young group having to disorder last time. For instance, we're either thoroughly evaluated at our own service and then around the country and it's now around any age disorder service in England. We know it is effective at reducing waiting times and improving clinical outcomes and it reduces the need for dedication and inpatient care by around the third. Which is really great to know people so a few will need to go away from their normal lives or intensive care but it also says that it makes us money. What we're trying to do now is continue scaling free so that you can do more in England and Scotland and Wales and Northern Ireland but also internationally as well. So that we really get away from this situation where there's a postcode lottery and how easy it is for you to access services we have to find really hard. We'll speak to the conferences, be able to get the services because they're currently out there. We do also recognize though that early intervention is hard for the solution. We have seen in other areas of psychiatry, particularly psychosis, early intervention can change the way particular presentation is viewed. Historically psychosis really was viewed as difficulty which you didn't recover from and psychosis services were about only quite accepted for the longer term disability. Early intervention has changed that so it's now really normal to think about promoting poor recovery, all living to potential and that is what we want to bring to disorders and the more people we get through early intervention pathways the more we change the long-term position and the long-term outcomes for these disorders. At the moment though we really want to make sure that we're thinking about how we can do access to everyone, not just those in that younger group with the relatively recent onset and a tailoring treatment for the needs of people across different disorder stages. This is a great research recently showing that core treatment at CVT are effective even if you've been unwell for many, many years so we know that these presentations, regardless of how you've been unwell can result in a world of treatment. But often that's slight differences in what people need depending on how you're going to be unwell. What people want, just based on their own personality and their own life. I think my take for a message really in how you improve outcomes is that intervention has to be important and working as a doer of faith and a really key part of the solution. But so too is putting everyone who needs a disorder on the table and trying to tailor what you're providing with the response that it's all and everyone can access care appropriately and normally. Talking about access, this is about diversity. So Salmiya Sina is a consultant for the characters with her 50 years in the NHS. She's been an eating disorder consultant in Sussex. Currently she works as a consultant in the private sector, has a particular interest in stress management, eating disorders, has cultural psychiatry and stigma and mental health. Salmiya is the founder of the Living Life Stress Free Limited, a registered college of Complementary Medical Association about stress management workshops and courses for professionals. She's a member of the World Registrarist and a fellow of the Complementary Medical Association. Salmiya, a question for you. How can inequalities affect access to eating disorder services? Thank you. I think I want to echo the theme today, which is funding. I'm really happy that Professor Andrew is here so we can take this message back. What I think, as we work as a consulting psychiatrist, as an eating disorder department, I felt that inequalities in funding became really strong because it's very low-fat. Imagine that services are not as well funded as the other fields of medicine. So we are behind, but I'm really pleased to say this is improving. So what happens is the inequalities in funding, what happens is most of the services are stretched, particularly in the NHS. So what happens is diagnosis like eating disorder or eating disorder are not otherwise specified. So some of these people suffering from these conditions don't stand a chance to access services. I believe they are big patients who have normal body weight or who have to more than average moderate weight. They usually have to run down for services. And a couple of years ago I did this review looking at the treatment-seeking behavior and treatment-receding behavior and what happened with minorities in Western countries. I felt that coming from at the minority background also is a disadvantage because there's a lot of diminishing bias and a lot of referral bias because of the lack of awareness among GPs and psychiatrists and other practitioners there was a consensus that eating disorder only affects the certain ethnic groups and not, for instance, the supply of blacks, it doesn't affect Asian communities it doesn't affect the same America as the Hispanics they were looking at that research. So what happens was Asians are poorly informed and symptoms are dismissed. So that is the inequality. Now I also came across, and I echo this back what James mentioned, is the fact that men are also a disadvantage point because men are eating disorders are usually identified as a sort of a percent of feeling obligation. Actually the research has shown that the percent of disorders are men so if you compare the treatment-seeking, the access to treatment is not corresponding with the actual the prevalence of the addition. The other thing I really found was, this is particularly rare, I mean not in the UK, but in other Western countries, a forward-looking treatment is a big factor in access to treatment, particularly for people who are on insurance and that most insurance providers they may not cover, certainly eating disorder conditions or they may not cover the land of the treatment. So that is definitely a big factor. Now the other thing that I would like to mention particularly relevant to give an order to say in the Western society is the concept of a culturation. So I was actually, I did talk about trans-cultural psychiatry, that's my one of my special interest and I think the process down upon a culture which means it is the process of integrating cultures and individuals of different cultures coming together and people who are more a-cultured, they had a better chance of access to treatment. Language is a big barrier and sometimes unfortunately certain cultures don't, it is the same as associated with mental illness we do need these orders and on some cultures and they will not seek treatment, families are not very forward-coming in the treatment. So I think that these are a combination of factors I would say at this point. And our final discussion last time I was smiling is Nadia Pak Nadia is a body image researcher and a PhD candidate at the Centre for Appearance Research at the University of West England in Bristol Nadia is interested in identifying how we can use a macro level change to foster positive body image and to help in the prevention of eating disorders. Nadia sits on the Academy for Eating Disorders Diversity Equity and Inclusion Committee to the Board of Directors and produces the Centre for Appearance Research's podcast Appearance Matters, which she co-hosts with Jane Payne Nadia, your question, what can be done for eating disorders beyond the clinic, possibly before the clinic? Thanks Dr. Well that's a really big and complex question and I'm not sure how well I can answer it in just a few minutes but I will see what I can do and hopefully we can discuss all the points maybe and any questions. So we're up until this point, we have laid out the foundation as to why we need to think about eating disorders beyond the clinic. So to recap I think quickly we know that a slightly more proportion of people struggling with eating disorders do not want to be adequate, kindly, specialist to care. So they're not even coming through the door. We then know that eating disorders are notoriously difficult to treat particularly when they've come for it and when my own experience has come for a second it's visible to everyone involved. And then of the society we live in, and this is where my research comes in, we live in a society in which disorder eating behaviour and cognition is encouraged, promoted or rewarded. We celebrate thinness, we kind of associate thinness with moral value which is wild when we think about it for a minute because our weight is mortally without genes and anything else. We also live in a society in which weight stigma is right and very challenging. I think the example of the cancer research through the campaign about the idea that there is the causes cancer is an example of which we are endorsing weight stigma, the weight demonetizing message. I think it's a simple science that we might see a correlation between obesity and cancer, but one-on-one correlation between equal causation and the message of hematocentrizing, right, but there's nothing useful and valuable about that. And then we also live in a society in which now things like lapses are sold in a millennial pink, I think there's a hundred or thousand followers and this is terrifying to me because I think it really came years ago, 50 years ago, lapses were a really difficult, shameful thing to buy. Now it's glossy and it's cool and that is not okay, that's not okay and this is absolutely what we need to come down on. And then the last thing we're going to talk about is the diet culture and I'm afraid it's very useful because we have a great diet and it's a huge billion dollar industry that's rooted on failure and it normalised, everything like cutting out food routes is normalised, not eating at seven times a day is normalised and we kind of feel like we're all done, we're all done, we're kind of gaining a health behaviour and absolutely is not. And I think the reason that we need to think about some of these cultural issues related to sort of eating habits and related to wasting the ideal of dinner is that of course eating disorders is not just about volume, they're not just about what we eat and what we eat, but it's very clear within the evidence that wasting up body satisfaction anxiety are all predictive of eating disorders. And the miracle of our society is kind of embracing that and celebrating that, we are bringing in a perfect law for eating disorder behaviour. So in terms of what we need to do beyond the threat, we need to be tackling wasting and hang on. Okay, we're not going to do anything fast and moving even sort of work forward, we're not having a wasting or we cannot know that. We need to really be teaching industry at all points for all young people in schools. Some products really should be allowed, some products that they would be thinking about are directives, absolutely should be allowed. And if you want to remember that the team where you're posting this TDA training initiative, where you should be able to really strike over Harvard, I think it's really kind of a quality work in that area to at this stage move directives behind the counter with the schools and for children under 16 not to have to buy them. It's really a first step in that area. That's what we need to do. It's always overwhelming. But yeah, I think we need a lot more. We need to be happy wasting head on. We need to be teaching industry, we need to be working with our businesses, our brands, and not just about learning about both of those things. We need to think about all of these things that are quality available and there's kind of a conversation that we have ourselves in terms of how we're really perpetuating this culture that is kind of endorsing the celebration for the evening. Thank you guys. With their well argued and sometimes passionate kind of range of topics, it's up to you guys. Questions from the floor? Should we take them to the floor? So we're going to wait for the microphone to come to you before you ask for a question. Can you use the word? I will. I just want to make sure that I see hands. So there's a hand here. Hi there. My name is Norma Collins. I have a more of a comment to the question because I was speaking to Aldo earlier and he said it was okay to give my success story really. I hope I can call it that. I really relate to what you were saying James. I am a champion voice of service students as well and I was fascinated by your piece about the care world that you proposed. I'm working with a very medical team that helped me get well after 18 years of relapsing and going in and out, taking the hospitals across the country and in France where I lived and so I've seen the worst side of easy disorder so-called treatment. But I have then found an extraordinary type of treatment in Oxford at the Warnton Hospital with Agnes 8 and then 13. And I finally learned what well meant and I became healthy and I have retained that health and I live in an amazing way. But what I want to suggest is that it is possible to build a new care model that can be accessible. It's the one that I'm working on with the Oxford team is based on not just weight. I was admitted at not a very low weight if that wasn't why I was admitted because of my weight. So that's an example that it is possible to get help without having to be about to die from malnutrition. They map each patient's journey onto a formulation that is individualised and personalised treatment for each person. Care exists in the community beyond the hospital. I know it's very important that we've talked a lot about hospital treatment but the idea of making a form of treatment that prevents having to go to hospital. A treatment in the community is something that we may need to address. Also using the arts in treatment that's my key method as arts, painting, poetry, reading is really crucial. We could maybe add that to the list of things that might work. And also working with co-morbidity. We haven't touched on that in any length yet. But if the Oxford model works on each individual case, I could get one. What I'm saying is I'm working with the very team that helped me get well and we are hoping to expand that as well. Thank you so much. I think it's always a tension between offering evidence-based care and one of the things that we're all trying to do is to make sure we use the best available evidence. But also personalising care and making sure it fits the needs of individuals. That's always a tension. Thank you for raising that. Sorry about that. Sorry, I don't have anything to say. Hi, so I know this is for me and I had to do this over about 25 years and it was only about 10 years ago that I sought help. So at the time that I sought help I kind of had quite a rapid introduction to the system. But that was because at the time I sought help I was far away to miss and then only given more intensive help once my weight got really quite low and it stayed that way for nine years up until last year. So I had sort of treatment on and off probably for about four years but in the end after all of that I tried to get more help. Essentially what I did was begin refeeding and becoming myself for the support of my brother. And the reason I'm mentioning this is because I don't know how much the attention is given to the experience of the people that have recovered outside of services to see how they managed to recover outside of services. So I don't consider myself recovered at the moment, I consider myself in recovery but I think there are massive people recovering and recovered who probably have a lot of input that they can give into kind of how people can recover. And I say that as well because one of the things that I learned myself outside of treatment was about extreme hunger which is something that I never learned within treatment. And I think there's something that most of the things I've learned in recovery have been because of the experience of the people that have recovered and learning what they went through physically in recovery which helped me not relapse ourselves in recovery. So I'm just kind of wondering about research that might have been done into the experience of the people that have recovered outside of services because it doesn't always have people in service to back it up for me. That comment and for highlighting something that I think has been on the radar I think there was a debate a few years ago at the European Eating Disorders Society about whether treatment had made any difference because there were some studies coming out to Scandinavia showing that people who didn't have treatment didn't do terribly differently from those who did. I don't think that the message overall, the conclusion overall was that the evidence was in supported treatment but clearly it's not going to work for everyone and as we've heard different things work for different people at different times. So I think we could generalise the whole search agenda from some of the conversations that we're having tonight. So thank you very much for the comments. Do you have a question for anybody? Or you just wanted to comment. It was more for the research and the lady that worked at the naughty. And I can say a couple of things. So I think we're really aware actually of how important it is that we have been to the people like yourself. What we've struggled sometimes with is how to find you. And we aren't trying to use social media more so that we're not talking with people within the clinic. As I've spoken about, as I've just spoken about, we know it's really hard for people to get to us actually and so there's also this issue that there's many people out there who never get over our threshold. So we are trying to navigate the world of Twitter and Instagram and we're not doing that that well but making an effort really to have a more community platform where we can have these conversations and we've got people who come in and spoke with us about ideas. We've never been our patients but we're connected with that way. So the research we're doing is also in that area and sticking with that theme of social media just as an example, a recent student of mine really did a qualitative study on how people have used social media to influence their recovery separately to treatment and trying to pull out the challenges of social media for that but also what people experience is beneficial because as clinicians we can sometimes be quite critical of social media and lots of people find it helpful. So we are trying to tap into these but I appreciate you raising how important it is. Peter Irons, I've got a daughter who has been using what has come into the social media and very much having a working experience now. She's also an anti-psychotic drug and I love the people sitting up over there. What has your experience been of trying to overcome the barrier of, oh well, the psychiatrist has described us, we can't go against. Are you saying that your daughter has been offered anti-psychotics as a treatment for eating disorders? I'm sure you're familiar with the contraindications of anti-psychotics. One of them is right there. It's a huge side effect of anti-psychotics. Was my arm in another area which has a sweet disorder these sweet sort of people say, well we can't handle this because she's on this anti-psychotic medication and I just wonder to what extent that response prevails in the eating disorder area? I'm going to answer very briefly and then James is going to say. First off, anti-psychotics should not be used for eating disorders. There's no evidence that they have any benefit in that context. If somebody is on an anti-psychotic and they're gaining weight because they have a psychosis, then what they should do is try and change the anti-psychotic and find one which doesn't increase weight. And that sometimes takes time. But absolutely should be done. Weight gain of the cardiacs you see with anti-psychotics is one of the reasons that people with psychosis die prematurely. Weight gain, they get cardiovascular disease, they get diabetes etc etc so there should be a plan to change the anti-psychotic to one that's less likely to do that. I think that's the point about the anti-psychotics which is something that I relate to. From my experience when I first had anorexia and was offered no specialist treatment I was put on a lot of anti-psychotics and it was justified for some reason and I didn't really understand why whether I should take them or not. And it was very effective in helping me gain weight which I think was the motive. But I think there's the main point that I'm taking from what you're saying is about when one service says it's that clinic's responsibility to deal with that and then psychiatry says it's that and somebody else says it's that. And in my experience in terms of your question about is that the case in eating disorders? As a patient that has been the case all the way through. There have been a lot of physical health problems. There have been a lot of times when I've been at very high risk and I've known people and friends who've sadly died because somebody hasn't taken responsibility for monitoring electrolytes for example and my eating disorders team said it's the GP's responsibility and then the GP was like no it's the eating disorders clinic responsibility and it was me in the end that had to find the solution and forced the GP to do it and make the appointment and forcing them to do it every so often and if I didn't make the appointment and go along they would never follow it up. Nobody would follow it up or the eating disorders people would tell me you've got to go and do it do your blood test. When I couldn't really get out of bed some days and the hope of just going to the doctor was too hard. So the consequence of that was that I was put at extremely high risk and every time I managed on the blood test I was whisked into hospital by everyone else and I'm really lucky that I didn't fall through the net even more so I think that there is, especially when you become an adult there's different the transition in terms of not just between services but in approach in terms of it's now your responsibility means that nobody else really takes the responsibility and you can really easily fall through the net so I think that is the case. Also the point that you said about people outside of services really kind of might relate because what I was thinking when you were speaking was about things that helped me in my recovery and a lot of them were not in services at all and that was always seen as an independent journey like I found mindfulness through a dialectical behaviour therapy group where you have to eat the raisin and all that stuff and I thought this is probably quite good this is probably what I need I find it really really hard so there's probably something in it but I would like to do more of that and they were like well go and find it yourself so I then had to go to the Buddhist centre myself and that was not seen as part of my treatment and I didn't have any support with that and then later on I found yoga which was the antidote to compulsive running which I gave up and have a look back eventually but to me those are really big parts of my recovery but I don't really or at the time didn't have the space to talk about in the therapy room it was always very focused on behaviour and weight and all that kind of stuff and not on the bigger person what do you want with your life there are so many things that we don't talk about in the therapy room and just one last example is for example nobody talks about sex and there's a massive implication in terms of in my experience there's a massive implication in terms of physical changes with eating disorders and I'm not talking about sexual orientation I just found it very difficult having a human sexuality not who I was attracted to and I never was asked about that and I did an equality diversity training with the meeting disorders service and asked them do you talk about this and they were all like no never talk about that that's separate that's for another clinic that's for you know that's for go and get counselling for that you know or whatever somewhere else and so I think it's all about the whole person not having to send the patient or the service user and everywhere and then having to take all the responsibility themselves so the services need to meet you with and share that responsibility a little bit because you know a bit of paternalism sometimes can take lives even if it's not in that I don't want it to be in that intervention kind of way but if my doctor could have taken on scheduling blood tests for me and chased me up when I didn't have them then that could have taken me out of some really risky situations so important message about holistic care absolutely, thank you, next question up there it's fine, I didn't see your hand it was the lady behind it why didn't you um negotiate between you and me I just want to say thank you first of all for the system, it's really interesting that I'm coming out this is like a general need and just a person who I want to go into working with the human nature source in the future it's not only interesting this evening hearing different ideas around recovery and also kind of thinking about you mentioned orthorexia and research and that and also this sort of body image idea, I've noticed kind of this is sort of a personal experience that a lot of people I know have been through using disorders and they quite open about that then seem to go down this path which I feel is sort of very trendy at the moment of this sort of like wellness, fitness, vegan, exercising on Instagram and I'm just wondering how that maybe ties into the role of recovery, whether that's a sort of healthy idea of recovery and just how that will sort of tie together do you want to pick a specific person to respond to that? why don't I start with the one you mentioned yeah I think in terms of research there's more research that is going out there, there's an association between these behaviors and disorderly thing, I'm not a clinician so I don't know much about the recovery process and also beauty process but there's not much yet on this behavior because it's quite new condition but there has been evidence that shows that people who have need to like clean eating or are vegan they will not do that for ethical reasons in mind, so mask, disorderly things in behavior, so we definitely this is like a broken record, we need more research into that I might just add if it's alright I think you've tapped into a really key issue in that as a field we're really more at what recovery is, we have research definitions that they vary as well and studies continue to define it in different ways but they don't always fit with kind of the lived experience and what matters to people so it's a really big issue and we don't know what we're working towards it's hard to get there but I think building on the research that Francesca referred to we often see clinically that what you describe is maybe a step on the journey to recovery and it's progress and we will roll with it in that sense but we perhaps would say that people who go on to maybe a fuller recovery also manage to leave some of those still quite driven and obsessive eating and exercise behind, not on me and something around social media something around social media, as I've learned over the years a little bit of why she was looking at it to check what a social media is like or what it's all about, next will be awareness and I'm going to say I've heard the quote up to say great, great, great things to say so how the media interprets eating disorders social people who are using Instagram, who are using Facebook and the other social media, they may go in there with a good purpose to get help but then they have a negative media image and I think that is a big problem, there is no regulation at the moment on social media unfortunately on Facebook and Instagram they need to take some more responsibility around what certain messages are coming up particularly the adverts, because the weight loss is a huge moving business so you know, the public intentions can be shared but if you just go on to a website to check you know, you don't know what website they could learn so I think it's safe to be on a safe side it's better to stick with the NHS you know, a website with different NHS on it or massive hands-on, those are probably the safer ones we don't have yet for us to follow but I think as Nadia was saying, I think you were also dealing with shifting culture, cultural norms are changing around these things 20 years ago when I started in the field veganism was very rare and it's not an image so what's normal is changing all the time so that's going to help people with perceived recovery as well I just wanted to jump in really quickly because I'm a yoga teacher, which is a bit of a cliche and I was a vegan for a very long time and I think one of the big achievements in my recovery recently was giving up veganism and hoping that no yoga students of mine are watching because you've got to cultivate the image but I'm very into Instagram and I think that I echo that point about maybe it's a step on the journey so for me, the yoga experience I found was a way to encounter my body in a slightly more healthy way yes, I was doing hot power yoga every day of the week but slowly over time I turned it down and that wasn't as bad as running 60 miles a week running on fractures and going out for a run and ending up in hospital so it's slowly over time softening and I think that's part of the journey and it's becoming more and more helpful and less and less unhelpful for me and I see that with students people can come to my class and use it as a form of self punishment they can come to my class and use it as a form of nurturing and pushing themselves maybe or relaxing and it's really hard as an observer to say who's doing what but sort of listening to people in terms of what's helping them or not is really important as well but I would say that maybe there's a lot of stuff around social media and for me personally because I'm here talking about my experience I guess I negotiate that quite carefully because if I post it's not a surprise that my most like picture on my Instagram is me doing yoga with hardly any clothes on, you know and so if I want to get more likes and more followers and get my message out which the message accompanying the pictures is usually a really positive mental health one I could go down that route is that going to be helpful for me? No, so I try not to do it but it's always a bit of a negotiation and like you said there's things like strongest the new skinny, all these kind of things maybe they're slightly more or slightly less harmful but hopefully it's part of a step along the journey Now the lady behind you wait in, thank you Hello, thank you coming to speak my question I'm on a training section on therapy and I wonder about the space for kind of other talking therapies in terms of eating disorders and I guess in particular psychedelic therapy and you know what's the relationship? I can make some comments I will say at the after I'm not a psychodynamic therapist so I say with that as a caveat I think we have to be guided by the evidence base but that doesn't mean the evidence base has got to be added to to be revised to be changed we know for anorexia in the most room particular there's increasing evidence that actually a number of therapies that are similarly effective we don't just have CBT anymore recent German study was comparing CBT to psychodynamic psychotherapy and psychodynamic psychotherapy was as effective however it took roughly two years to bring about effects compared to roughly six months but some people will respond perhaps better for that approach than others we've also got the Maudsley anorexia and anorexia treatment for adults developed out of our service which is more of a cognitive interpersonal model and I think we've really recognised that there is a lot more to do to improve the treatments we have in psychodynamic psychotherapy to fill that gap and brilliant as clinicians in the NHS I think we do have to be guided by the evidence and the clinical guidelines but that doesn't mean we can't continue to change them and I'll just add that there is a psychodynamic psychotherapy recommended by nice four young people as well as an alternative and many of those treatments don't work so it's there but I think a lot of the medical research it's essentially the evidence base is only as good as the research and it's an area the psychodynamic psychotherapy is an area where the research has been less than in other types of therapy and that's probably one of the reasons that it's not it's not prominent at all so you may need to change that we would love to see it I wanted to jump in again sorry because I'm really passionate about like a therapy and longer term work without being available to people and sort of getting away from a one size fits all model and I think that when I finally accessed treatment I was put through CBT first without really being asked just because it was the first thing on the list and it wasn't really appropriate for me and I found that I failed I said to myself I failed this because it didn't work for me and it made me feel worse and less hopeful so I would sort of go with that point about the evidence base but for me the most consistently evidence thing is the therapeutic relationship you know across all the things so if you don't have the relationship nothing is going to work doesn't matter how fancy it is, how good the manual is whether it's pushing it or however well funded it is if you don't have the relationship it's not going to work so I think that that has to be established first as part of the therapeutic process and establishing a relationship isn't a manualised therapy unfortunately but it is the fundamental thing and the evidence that the best sort of evidence is not the published literature not to disrespect anyone but it is the person in front of you so in terms of what might work most of them, what are they telling you so I would always refer that always trumps any sort of guideline of what should come first or second for me Thank you and thank you for the observation we're running out of time but we've got a couple more questions and you're ready there Hello, good evening My journey started in the early 80s and it started in the mid 90s where I had an intensive care I didn't want to talk to anybody about it because it was so strong the obsessiveness and the self-control I had I feel I'm healed now and it went all the way through until the sort of early to mid 2000s but I'm not sure if anybody spoke about people that don't go for help and don't want to go for help because our sessions are so strong every time they look in the mirror they just don't go for help that was my mentee Thank you Thank you for your comment Did it make sense? It did, thank you We've got some questions Are there any more questions from your floor? We've got some questions from Twitter We've got some I'm a member of a charity called Eating Disorders Support and we run a health line and so many people who call us won't go and get proper help because they're frightened of being weighed Why does a counsellor have to weigh them every time they see them and they won't go? So many people have it again and again Would anyone care to respond? So I think it links absolutely with the messages around you to do more at community level to help people feel that they can go and seek help Weighing is a really tricky issue There's a campaign that you might have come across like Hope Virgo is another kind of expert by experience which is more around getting rid of weight as a criterion for services which I think is really important about saying we shouldn't be deciding we get treatment just by being on it I think the issue of being weighed in treatment is a tricky one because somehow we have to safeguard people medically and weight is part of that if they're underweight We always try to have a conversation with people about it and work with where they are at to come up with something that's going to be accessible to them as well as to facilitate their treatment For CBT there is a really strong evidence base that being able to tolerate knowing your weight is important as part of treatment and recovery but again we want to have a conversation with people about that but getting them to us is the first step for us to be able to have those dialogues which is why we need to do more at community level Just Dan I think what James has said is key to this which is I don't know if we're eating disorders I mean I do sometimes but it's primarily if they're homeless but absolutely key to this I think this is true for the whole of mental health the first part of the call is that you have a conversation that you talk to someone about what they want you develop a relationship within which you might then say to them do you think it might make sense that we do weigh you because you look very thin now that's a very different thing to pushing someone on to scales every time they walk through the room so I think it's really key that it's based on a very basic relationship we are sadly when we have time there are quite a lot of questions coming in from Twitter and elsewhere but we're not going to have time to do that to them I just want to read a couple out because they kind of take us on to topics that we haven't covered so far one was how can we ensure that anti obesity campaigns don't have unintended consequences such as increasing the risk of disorder eating there's one here on what we do to improve the education of doctors across the profession not just those with specialists how can we improve eating disorders awareness and training for teachers parents and anyone we need to listen so that symptom recognition is better early on so many interesting conversations that we could if we have time how are we thinking about it together but I think I'll go show you what we need to wrap up now thank you all for being here thank you enormously to all of the speakers the presentations and comments and onwards and upwards with campaigning for more investment in the search and service development in this area so thanks to all of you who are already contributing in that area we'll end with that