The
Eating Disorders Service - South
London and Maudsley NHS Trust
The
Trust
The South London and Maudsley NHS Trust is a
flagship Mental Health Trust with a total budget in excess of
£170m. One unique feature of the Trust is its close link
with the Institute of Psychiatry, which is a world-leading centre
in psychiatric research and development. Because of these links
the Trust has a substantial Research & Development Contract
with the NHS (value £18 million).
The
Eating Disorders Unit
The Eating Disorders Unit is part of the Specialist Directorate
of the South London and Maudsley NHS Trust. The Unit has been
recognised as providing a range of high quality services for
patients of all ages, and across the spectrum of eating disorders.
The Unit currently receives over 800 new referrals per annum
and a large proportion of these are offered treatment. As well
as serving the local population in South London it also accepts
many national referrals.
The
care-team is committed to an evidence-based stepped care approach
to treatment. Care packages range from manual-based or computerised
self-help, to more complex psychological therapies, through
to day-care and in-patient care for the most severely ill. Aftercare
is provided in close collaboration with Denbridge House, a Richmond
Fellowship Hostel. Carers are actively encouraged to participate
in treatment.
The
Unit also has a large research portfolio, with the aim of increasing
our understanding of the causes of eating disorders, and of
developing better treatment for sufferers.
The
quality of care packages is assessed through a comprehensive
outcome monitoring system. Over the past three years the Unit
has received a number of accolades: in 2000 it received the
Croydon Health Award for excellence, and was quoted in on the
BBC website as a site of research excellence. In 2001 it featured
in an article on good practice in Breakthrough, a mental health
user magazine. And in 2002 it was held up as an example of positive
practice in women's mental health by the Department of Health.
Senior
staff
Medical:
Prof. Janet Treasure, Prof. of Psychiatry at Guys Hospital,
Dr. Ulrike Schmidt, Senior Lecturer in Psychiatry, Institute
of Psychiatry, Dr. Peter Webster, Consultant Psychiatrist, South
London and Maudsley NHS Trust; Dr Mima Simic Consultant Child
and Adolescent Psychiatrist, South London and Maudsley NHS Trust.
Psychology:
Dr. Ivan Eisler, Senior Lecturer in Clinical Psychology, Institute
of Psychiatry and Mr. Padmal Da Silva, Institute of Psychiatry,
Miriam Grover, Dr Anna Lavender, Dr Najma Khan-Bourne, Michael
Rooney, York Clinic Guy's Hospital, Wendy Blake, Lubna
Mohammad.
Nursing:
Ms
Gillian Todd, Clinical Nurse Leader
Lynn St Louis, Deputy Clinical Nurse Leader
Alison Carolan, Day Service Team Leader
Services
The Unit comprises of the following:
-
A
17-bed inpatient unit which functions as a national unit as
part of the NHS R&D facility and also provides a service
to local patients. The ward is located in Tyson House at the
Bethlem
Royal Hospital. The ward accepts patients aged 14 upwards
with severe anorexia nervosa, acute or chronic.
-
Aftercare
is provided at Denbridge
House, a Richmond Fellowship Hostel.
-
A
day-patient service with 10 full-time places, which is based
at Larkbarrow House at the
Bethlem Royal Hospital. This service accepts referrals either
post-discharge from the ward, or directly from outpatients.
-
Out-patient
and community services are provided for local and national
patients at several sites including the Maudsley Hospital,
Guy's Hospital and the Bethlem Royal Hospital.
-
A
specific service for children and adolescents, based at the
the Michael Rutter Centre, Maudsley Hospital, provides (i)
outpatient treatment (ii) intensive multi-family group treatment.
- We have
close links with Denbridge House, a Richmond Fellowship Hostel
which provides aftercare for patients with severe eating disorders.
Care
packages
Assessments
Assessments are conducted by senior clinicians. Assessment
includes a detailed interview with the patient, separately
and jointly with her/his carers, with the aim to;
-
Forge
a good relationship with the individual and her/his family;
-
Gain
a good understanding of the aetiological and maintaining factors
of her/his case and developing an individual case formulation;
-
Assess
the severity of the disorder and any physical and psychological
risks;
-
Develop
a comprehensive care plan collaboratively with the patient
and her/his family;
-
Give
feedback to the patient on the psychological formulation and
on risks and their management. Feedback and further information
are given verbally and in writing, using a number of tools,
including an individual assessment letter to the patient,
charts summarising medical risks and our self-help
books.
Outpatient
care
Referrals are taken from General Practitioners and Consultant
Psychiatrists for regional patients and the latter for national
ones. We accept referrals of all forms of eating disorders
and provide assessment for opinion and also offer treatment
packages for anorexia nervosa, bulimia nervosa and atypical
eating disorders (see under therapies offered). Currently
the waiting list is in the order of 4-8 weeks for assessment.
Assessments are done by specialists in eating disorders which
come from all parts of the multi-disciplinary team.
The Child and Adolescent Team
The team, led by Dr Ivan Eisler and Dr Mima Simic, provides
assessment and treatment for a wide range of complex eating
disorders such as anorexia nervosa, bulimia nervosa, and atypical
conditions. Referrals (both local and national) are accepted
for all patients, up to the age of 18, with a diagnosis of
an eating disorder. We can also provide an assessment or second
opinion in cases where the diagnosis is more difficult to establish,
such as anorexia nervosa in younger children or bulimia nervosa
in adolescents. Even though we receive referrals with a wide
range of severity, the majority are treated effectively on
an outpatient or day basis. Where admission is required we
liaise closely with the Gerald Russell inpatient unit. Referrals
are regional and national.
Day-care
This is offered for regional patients at Larkbarrow House
and it offers up to 3 day a week care for 8 patients. Referrals
come from GPs, psychiatrists or the Gerald Russell Unit. The
multi-disciplinary team is led by the regional consultant psychiatrist
and community team leader and it offers specialist dietician
management, as well as the full range of group and individual
therapies.
In-patient care
The Gerald Russell in-patient unit is situated at the Bethlem
Royal Hospital and has 17 beds for the treatment of severe
anorexia nervosa. It treats females and males from aged 14
years upwards. It is run by the multi-disciplinary team under
Professor Treasure, the regional consultant psychiatrist, the
deputy clinical nurse leader and consultant psychologist. It
works on a motivational model of treatment both in terms of
re-feeding and the therapies used. From the outset a large
emphasis is put on the integration of treatment with the needs
of carers and all individual and group therapies are occur
in the context of supportive family work.
The
Multi-Disciplinary Team:
The
unit works in a multi-disciplinary way aiming to utilise the
skills of all the members. The team includes the:
Medical
Team:
This consists of three consultants, a full time senior registrar
and 2 full-time junior ward doctors. Their role is to provide
medical and psychiatric care for the patients and the consultants
take lead clinical responsibility for each patient. The psychiatrists
have roles in all parts of the services, from assessments,
in-patients, day-patient and out-patient therapy.
Nursing Team:
The clinical nurse leader, Gill Todd, manages the nursing staff
delivering care in 4 community teams and the inpatient team.
Each community team has a team leader; the in-patient team
is managed by the Deputy Clinical Nurse Leader. Nurses make
up about 66% of the care delivery staff. Nurses have expertise
in re-feeding, developing a therapeutic alliance, supervision,
equal opportunities, behavioural programmes and motivational
enhancement therapy. Nurses are involved in the delivery of
all of the inpatient and outpatient treatment packages they
also support the other disciplines in the care they give.
Psychologists:
The clinical psychologists work primarily with cognitive behavioural
models to develop a shared idea about the factors involved
in the development and maintenance of patients' difficulties.
Thus unhelpful thoughts, beliefs, emotional and behaviour patterns
that contribute to people remaining unwell are challenged.
This work is for eating disorders specifically, or additional
problems that often go along with eating disorders, such as
obsessive-compulsive difficulties, depression, low self-esteem,
and social anxiety. The psychologists also work with other
members of the staff team in planning and decision-making with
patients, and specifically on advising the team on psychological
aspects of patient care. They also run a teaching group for
staff on how psychological ideas can be used in thinking about
and working with patients.
Occupational
therapists:
Occupational Therapy is concerned with the meaning and purpose
that people place on occupation and activities in their daily
life and how having an eating disorder can impact on their
ability to carry out these occupations and activities. The
Occupational Therapy Service provides assessment and treatment
aimed at improving patients ability to function in the areas
of self care, productivity, and leisure skills. Treatment
takes place on an individual and group basis, examples of
sessions available are meal planning and cookery, meditation,
assertiveness training, anxiety management, creative expression,
creative art and body image work. Aikido, Dramatherapy and
Guitar lessons are also available on the unit.
Dieticians:
Kate Trotter is the Chief Dietitian. The dieticians fulfil
two main functions as part of the eating disorders team.
The first is to work with the caterers to plan the menu,
so that it provides food that achieves weight restoration
in a way that is as safe and effective as possible. They
also try to use the food service to give examples of ordinary
meals, to help patients learn to feed themselves using normal
foods. Kate arranges regular meetings on the ward for the
catering manager to meet staff and patients, to make improvements
and solve problems. Secondly, the dieticians work with individual
residents and their primary nurses, mainly to plan how they
will eat to manage their weight and maintain good nutrition
but also to deal with specific problems with nutrition, eating
and health.
Social
Worker:
Wendy Whitaker, our social worker, is involved in the all the
social issues and liaison with outside agencies that arise
with in-patients. She is also actively involved in individual
and family therapy on the unit.
Therapies
offered:
Motivational Enhancement Therapy
People with eating disorders often find it hard to accept that
anything majorly is wrong with them, or that it is within their
power to change. MET is often the first step in treatment.
It helps the patient own the illness and explore their reasons
for continuing in the illness against their reasons for moving
forward to health. This therapy is based on a widely used model
of health behaviour change which states that two factors need
to be addressed for sustained behaviour change; first a recognition
of the importance of a problem, or conviction that change is
needed and second the degree of self-efficacy which reflects
confidence in one's ability to bring about a particular behaviour
change successfully. In contrast to conventional medical models
where the health professional is the expert and the patient
the passive recipient of education and advice, MET elicits
the patient's concerns as the expert on her/his difficulties.
The effectiveness of MET has been widely demonstrated across
a broad range of problems. We practice MET on a one to one
level but this approach also provides a philosophy of our unit's
treatment.
Family
Interventions
This occurs in all areas of the service for adolescents and adults,
and the Maudsley model of family therapy is used world wide.
Careful multidisciplinary assessment includes individual and
family interviews, physical examination and biochemical screening
tailored to the particular needs of the individual referral.
The treatment draws on many years of our own research and clinical
experience which provides strong evidence that the most effective
way of helping children and adolescents with an eating disorder
is through supporting the family. Generally the treatment therefore
involves both the parents and the child or adolescent and sometimes
other family members e.g. siblings. We emphasize strongly that
the family needs to be involved not because we see it as the
cause of the problem but because they are the best resource
to help the young person overcome her illness. The treatment
usually lasts six to twelve months. Initially treatment sessions
are intensive (e.g. weekly), but later less frequent attendance
is needed. In recent years we have developed a multiple family
brief intensive day treatment programme for groups of families
where families have the opportunity of exchanging experiences
and provide support for one another. The family group treatment
has received highly positive feedback those who have taken
part. We have a strong commitment to continue to evaluate the
effectiveness of our treatments and from time to time we may
approach families for permission to include them in such evaluative
studies.
Cognitive Behavioural Therapy (CBT)
This is the leading evidence-based treatment for patients with
bulimia nervosa and related disorders and is offered as first-line
treatment for most out-patients with these conditions. Patient
and therapist work collaboratively to develop a joint understanding
of the thoughts, feelings, behaviours and physical sensations
that underlie and maintain their illness and how these interact,
keeping the person "stuck" in their illness. The aim
is to help people develop new skills for identifying, managing
and overcoming unhelpful and problematic thoughts, difficult emotions
and problematic behaviours. The treatment is structured and care-fully
designed in-between session tasks are used to help people to try
out and practice new and more helpful ways of thinking and behaving.
Work-books, self-help books and an interactive CD-ROM are used
as part of the treatment.
Cognitive
Analytic Therapy
This
is a form of therapy that helps patients understand more how
their eating disorder may be tied into beliefs and feelings
that have arisen from relationships and experiences in a
sufferer's past. It is a therapy that has grown out of an
integration of psychoanalytic therapy (more specifically
'object relations theory') and cognitive therapy. By understanding
and processing difficult feelings and unhelpful beliefs,
whilst challenging some of the counter-productive ways people
use to manage them, patients are helped to move forward in
their process of recovery. It is offered in all parts of
the service to patients, where it is suitable.
Carer
and patient involvement
The care-team at the Unit is strongly committed to the involvement
of patients and their carers in the treatment. Jointly with the
Eating Disorders Association,
the Unit runs regular conferences for carers and users, and there
is a regular carers' group. Carers are involved closely in developing
plans for relapse management for inpatients, to be followed through
in either a multi-family group setting or in individual family
work. For information
about Family Work on our unit click
here.
Current
research activities
Staff, patients and family members are encouraged to take part
in the research projects conducted by senior members of the team.
All the research aims to further our understanding of the underlying
causes of eating disorders and to develop better treatment for
sufferers. For further information on the research activities
of the Eating Disorder Unit please click here.
Evidence
base for the service
All the individual care packages are evidence-based, and all the
psychological interventions used in the Unit (using motivational,
cognitive-behavioural, cognitive analytical and family systemic
strategies contained in workbooks, manuals and CD-Roms) have been
subjected to rigorous clinical trials. The Unit is constantly
trying to develop new interventions and refining those already
tried and tested. It has been shown that treatment on the Specialist
Unit not only gives patients and their families greater insight
and understanding of the illness, but also motivates patients
to achieve a successful outcome.
Over
the past decade the Unit has received research grants of more
than £1.1 million to develop and evaluate clinicians' tools
and manuals (see below). The outcomes of clinical trials have
been published in peer reviewed journals.
- 1993 BN: Self
management / CBT (Treasure 1994, 1996;Turnbull 1996;Thiels 1998;
2000;2001).
- 1997 BN. CBT and Motivational interviewing
(Treasure 1999;Katzman submitted)
- 1998 AN. Outpatient management. (Treasure 1995, Dare 2001)
- 2000 Adolescents CBT & Family therapy (in progress)
- 2001 CDRom delivering BN treatment (in progress)
