Psychiatrists, milieu and glue
Authors: JANICE RUSSEL
Journal: World Psychiatry (2009)

K. Halmi states unequivocally in her thorough appraisal that the psychiatrist should be “captain of the multidisciplinary team”, and correctly so, as only the psychiatrist would be expected to be suitably equipped for this role. It is, however, becoming difficult to interest psychiatrists or even physicians in taking this on, whilst other health professionals are being attracted in increasing numbers by better health insurance rebates, evidence based treatments and even prescribing rights. Thus, Halmi's ideal might become progressively less achievable, unless the reasons why suitably qualified medical practitioners avoid eating disorders can be understood and addressed. In every component of a comprehensive eating disorders treatment program, the need for regular multidisciplinary team meetings cannot be stressed too greatly. These represent a forum in which team cohesion can be facilitated, treatment goals formulated, progress gauged, ongoing iterative knowledge of each patient developed and roles for team members clarified with support and direction for the challenges presented. Patients and carers should also have a voice. When treatment outcomes are disappointing, which they not infrequently are, psychiatrists, team members and the program might become a repository for the anger and disenchantment of patients, families and carers. Not only can this result in complaints, non-payment of accounts and disputes about services rendered, but it can become a source of great angst, demoralisation and a major disincentive for the perfectionistic clinician. This burden needs to be shared, but ultimately treaters, particularly the psychiatrist who leads the team, will benefit from their own supervision, support and often therapy. Milieu is an important element of all components of the program. It serves a “holding” function, which is most easily defined in the inpatient situation but still operates in day programs and outpatient clinics. In the first two, it includes the nursing staff, their unconditional respect and their availability for identification and modelling 1. When patients are attending an outpatient clinic, contact with administrative staff and the physical surrounds serve to keep them in treatment whilst they begin to manage their lives outside. Milieu in full or partial hospital programs also includes meal support and supervision. In our own inpatient program, much to our surprise, this was rated most highly by patients, who told us that this, in particular, was what they could not get at home 2. One would hope that, as the patient moves through the components of the program, which should include work with his or her immediate support system, this would no longer be the case. The “Maudsley method” of empowering parents of anorexic children and younger adolescents is a way of providing a more appropriate milieu for these patients — when it works. Not all parents are equal to the task, and it can be a major imposition for siblings. Nevertheless, ample research seems to support its efficacy, even if it would be expected to become less developmentally appropriate from the mid teens 3. The “New Maudsley method” 4 is based on the increasingly realistic premise that older patients might take considerably longer to recover, if indeed they do, and the cost to their families can be considerable. A skills-based manual uses animal metaphors to describe desirable and undesirable parent or carer behaviours, which can equally apply to health professionals working in a multidisciplinary treatment setting. Parents and carers must be helped not only to take care of themselves, but to collaborate with the patient's effort towards recovery. It would seem that less ill eating disorder patients, i.e. those requiring less behavioural containment, can recover with a variety of therapeutic approaches and treatment settings. The contingent of older chronic anorexia nervosa patients, however, seems to be growing apace and presents an increasing challenge. Thus far, pharmacological and endocrinological treatments have had relatively little impact, contributing to the lack of increase in recovery rates in the last two decades 5. Furthermore, the outlook seems to be worse with the greater number of failed inpatient admissions, but longer admissions have been shown to reduce metabolic factors in self-perpetuation of weight loss 6. These are the patients who often present clinicians with dilemmas around involuntary treatment and for how long this is still worthwhile 7. Patients with anorexia nervosa rarely request palliative care, yet we are often in a position where we might feel that this is all we can offer and what we offer is far from ideal. The “glue” that holds the salient components of treatment together is often the general practitioner or primary care physician, whose role in eating disorders includes establishing engagement, early recognition and intervention. The latter might begin with referral to a specialist dietitian and/or psychologist, but is likely to eventually include referral to a component of a multidisciplinary program, then monitoring and support after the inpatient phase. The primary care physician or general practitioner often has the unenviable task of persuading patients and their parents, partners or carers that they need to return to or persevere with one component of the program. Communication with personnel from the multidisciplinary program is absolutely essential, and patients’ general practitioners and primary care physicians must receive adequate information, support and education for working with a supremely challenging group of patients and their families.