Squaring the circle

✍ Scribed by Bob Palmer

• Publisher: John Wiley and Sons
• Year: 1999
• Tongue: English
• Weight: 32 KB
• Volume: 7
• Category: Article
• ISSN: 1072-4133
• DOI: 10.1002/(sici)1099-0968(199906)7:3<232::aid-erv292>3.0.co;2-a

✦ Synopsis

Winding up

Squaring the Circle

The whole business of helping people with severe anorexia nervosa is full of dif®culties. (Although it is not, of course, as taxing as is the business of getting better for the sufferer herself). There may be problems of therapy, of clinical management and of service organization. By therapy I mean the usually sustained interaction between a clinicianÐor group of cliniciansÐand a patient that aims to help the latter to change psychologically and thus to allow her to change physically also. Therapy comes in various ¯avours but these can be ignored for the present argument. By clinical management, I mean the pattern of contact between the clinician and the patient and the additional means, such as inpatient or day care, which may be provided to help the sufferer with weight gain and so on. Lastly, there is the issue of service organization, which includes the way in which these are put together and the overall context in which they occur. There are potential dif®culties in each of these areas but there is a real dilemma at the heart of service organization.

This dilemma arises because anorexia nervosa is not common and the treatment of its more severe forms is a specialized business. Clinicians skilled in its therapy may be scarce but are potentially mobile; the more specialized forms of clinical management are not. As a rule of thumb it probably takes a population of about a million to justify a special inpatient provision for adults with the critical mass to sustain a culture which can in turn sustain severely ill patients. (A similar service for the very few children who require admission would need to relate to an even greater population). The personal business of therapy needs to be sustained over months and yearsÐand should ideally be local. The additional and more intensive forms of clinical managementÐespecially admissionÐare better aggregated into specialist centres and will almost always be required for fewer people and for a shorter time than therapy. What kind of service organization would allow the minority of patients who need admission to have the same therapist before, during and after their time in hospital? Or at least to have a total treatment experience which is not fragmented and bitty? That is the circle to be squared.

Various documents invite us to provide local, accessible services. I will give a cheer to that. Likewise, safe, experienced and specialized centres for the intensive treatment of the severest cases also deserve a cheer.

However, three cheers go to forms of organization that allow these two things to be combined into a seamless service, and not only in the big cities.