Nibbles

Stuf®ng the Christmas Turkey

David Clinton*Huddinge University Hospital, Huddinge, Sweden

Ever since I lost my copy of Mrs Beaton's Cookbook in the back of a squad carspeeding along Muswell Hill Road I've been searching for an authority on howbest to stuff the Christmas turkey. My discerning guests demand satisfaction.And what with the advent of a new millennium, the problem had a greaterpungency this season. Thus began my scienti®c search for the superior stuf®ng.

My ®rst thought was to seek guidance in the eating disorder literature, so Iturned to the haute cuisine of comparative treatment research, the randomizedcontrolled trial (RCT). We've read a lot about these recipes lately. One of themost recent ones concerned adding low-dose imipramine to dietarycounselling with psychological support in the treatment of obesity (Laeder-ach-Hofmann et al., 1999). Last year Wilson (1998) presented a spicy defenceof the RCT's culinary merits. He maintains that RCTs have establishedcognitive behaviour therapy (CBT) as the `®rst-line treatment of choice' forbulimia nervosa. Although acknowledging a need to improve upon theoutcome of CBT (about 50 per cent of patients are symptomatic at the end oftreatment and 5 years later) he sees this happening through various culinaryre®nements of the present recipe (Wilson, 1999).

So if the RCT could solve the problem of treating bulimia nervosa surely itcould be applied to my kitchen conundrum. Feeling inspired, my mind leapt atthe promising implications, and I started planning my own dining room RCT. Icould ®rst blindfold my guests and then present them with a random scheduleof carefully controlled and consistent stuf®ng mixtures of various ¯avours. Ofcourse, I'd need standard outcome measures of taste, texture, aroma,palatability, seasonal savouriness, etc., but that would be a tri¯e.

Unfortunately, my wife put a perfunctory halt to these plans. She was quickto point out that her mother was not going to allow herself to be blindfoldedand experimentally fed at my dinner table. She predicted a problem of com-pliance, and I was forced to agree. Nevertheless, given the results of last year'srandom errors in the kitchen the blindfold was not something to snub.

CCC 1072±4133/2000/010076±04$17.50 European Eating Disorders ReviewCopyright *c 2000 John Wiley & Sons, Ltd and Eating Disorders Association. 8(1), 76±79 (2000)

European Eating Disorders Review

Eur. Eat. Disorders Rev. 8, 76±79 (2000)

*Correspondence to: Dr David Clinton, Centre for the Study of Eating Disorders, Huddinge UniversityHospital, M57 141 86 Huddinge, Sweden. Tel: 46-8-58585796. Fax: 46-8-58585785. E-mail:DAVID.CLINTON@neurotec.ki.se

However, I had to surmise that the randomly controlled turkey was turning outto be a ®ckle fowl.

Yet I persevered. Of course, there was solace to ®nd in the literature. TheRCT has been running into criticism ever since Seligman's (1995) analysis ofthe Consumer Reports Study of Psychotherapy. The argument being that whatthe RCT may possess in terms of internal validity (i.e. experimental controlsthat eliminate alternative explanations of the results) it also lacks in terms ofexternal validity (i.e. applicability to the real world of psychotherapy as it ispractised, or turkeys as they are stuffed).

The major alternative to the ef®cacy-based RCT study is the effectiveness-based multi-centre study. Outside the eating disorders ®eld, Wells (1999) haspresented a delicious discussion of the relative merits of these approaches, notto mention the contribution of Treasure and Kordy (1999) in the presentjournal. Although acknowledging the contribution of RCTs, they advise us tobeware its glitter, and argue for the applicability of well-designed large-scaleobservational studies of treatment as it is practised.

Surely this meant the solution of my perplexing poultry puzzle. It was timeto turn the diversity of stuf®ng recipes and kitchen practices to advantage.However, I soon realized that implementation promised to be foul matter.Years of fastidious observation loomed on the horizon, perhaps hundreds ofdinner guests in strange surroundings. My hungry holiday guests would bearriving all too soon. No, the multi-kitchen study was not to be.

I was now desperate. Surely there must be a scienti®c method for solving myproblem. It was then that I asked myself whether perhaps I was just trying to®ll the wrong fowl. I recalled another one, the Dodo from Alice in Wonderland.Of course, we all remember Luborsky's (1975) challenging article about theDodo. In a provocative review of comparative psychotherapy research heconcluded that although it is clear that psychotherapy has a signi®cantpositive effect, it has become equally clear that no one form of therapy isgenerally superior to another. He thus wondered if the lack of conclusive®ndings justi®ed the Dodo's verdict, that `everyone has won and all must haveprizes'. A generation later we are still grappling with Luborsky's challenge.

Clinicians know that the same form of therapy can lead to radicallydifferent effects for different patients, while these forms of therapy differ verylittle in effect between themselves `on average'. However, we researchers seemto show little curiosity about understanding and explaining this phenomenon.We are obsessed with between-group differences, but complacent in the face ofimportant within-group variance. I soon saw the simple interactionalimplications for my Christmas guests. My savoury sage and onion was boundto go down well with some of the guests while others would be craving thesausage and chestnut variety.

Although this question of guest versus stuf®ng interaction is intuitivelyintriguing, it has received little systematic attention. Within the eating

Eur. Eat. Disorders Rev. 8, 76±79 (2000) Nibbles

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disorders ®eld some have dismissed the notion of matching because ofdisappointing results in other areas (Treasure and Kordy, 1999), whileacknowledging the well-established recommendations of Russell and co-workers (1987) that family treatment is to be recommended for the treatmentof eating disorders during adolescence. A recent paper that indirectly toucheson the question of patient characteristics associated with differential treatmentresponse comes from Bulik and co-workers (1999). In a stimulating article theyfound that frequency of binging and the personality variable `self-directedness'were predictors of positive response to a brief course of CBT for bulimianervosa.

At last I saw the light. We are not just entering a new decade of eatingdisorder research, we are meeting the dawn of a new century of savourystuf®ng. My hope is that we develop a complementary research emphasis thatwill mean the integration of ef®cacy and effectiveness through closer attentionto systematic evaluation of the relationship of within-group differences tooutcome. I recall how Treasure and Schmidt (1999) conclude their appetizinganalysis of ef®cacy and effectiveness research. They maintain that thecomplexities of the interactions that determine response to treatment will beunderstood by conducting research in `a spirit of co-operation, humility andcuriosity'. Truer words were never spoken, nor a more challenging goal everformulated. For the time being, lacking an authority of Mrs Beaton's stature,I'm afraid I decided to stuff my turkey in the usual way, with at least two kindsat both ends. Back to the chopping board.

REFERENCES

Bulik CM, Sullivan PF, et al. 1999. Predictors of rapid and sustained response tocognitive-behavioral therapy for bulimia nervosa. International Journal ofEating Disorders 26(2): 137±144.

Laederach-Hofmann K, Graf C, et al. 1999. Imipramine and diet counseling withpsychological support in the treatment of obese binge eaters: A randomized,placebo-controlled double-blind study. International Journal of Eating Disorders26(3): 231±244.

Russell G, Szmukler G, et al. 1987. An evaluation of family therapy in anorexianervosa and bulimia nervosa. Archives of General Psychiatry 44(12):1047±1056.

Seligman MEP. 1995. The effectiveness of psychotherapy. American Psychologist 50:965±974.

Treasure J, Kordy H. 1999. Evidence based care of eating disorders: Beware the glitterof the randomised controlled trial. European Eating Disorders Review 6(2):85±95.

Treasure J, Schmidt U. 1999. Beyond effectiveness and ef®ciency lies quality inservices for eating disorders. European Eating Disorders Review 7: 162±178.

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Copyright *c 2000 John Wiley & Sons, Ltd and Eating Disorders Association. 78

Wells KB. 1999. Treatment research at the crossroads: The scienti®c interface ofclinical trials and effectiveness research. American Journal of Psychiatry 156:5±10.

Wilson GT. 1998. The clinical utility of randomized controlled trials. InternationalJournal of Eating Disorders 24(1): 13±29.

Wilson GT. 1999. Treatment of bulimia nervosa: The next decade. European EatingDisorders Review 7(2): 77±83.

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