Using the experiences of COVID to reposition services for children and adolescents with anorexia nervosa

We outline a four-session tutorial series developed for medical students during their psychiatry rotation, prompted by a letter from a medical student articulating the confronting nature of the rotation. The series addressed recommendations of a binational consensus statement on medical student well-being in providing a mental health promotion initiative that promoted peer support, well-being and alleviated stress.

A reflective practice group tutorial series for medical students Dear Editor, Defined as 'the process of engaging self in attentive, critical, exploratory and iterative interactions with one's thoughts and action… with a view to change', reflective practice (RP) has become a core feature of medical education. 1 Given benefits of RP for professionalism, well-being and decreased isolation 2 if ever was the time to utilise RP in medical education, it is now. 3,4 We outline a four-session tutorial series developed for medical students during their psychiatry rotation, prompted by a letter from a medical student articulating the confronting nature of the rotation. The series addressed recommendations of a binational consensus statement on medical student well-being 3 in providing a mental health promotion initiative that promoted peer support, well-being and alleviated stress.
Offered over four consecutive weeks during four psychiatry rotations in 2021 in an Australian medical school, tutorials were held face to face and were not mandatory (attendance not recorded but timetable-listed). Rationale for the tutorials, as provided, was: As is appropriate, most of medical education focusses on patient factors; however, patients and their illnesses are understood in various contexts and always through the prism of a relationship with their healthcare provider. This series was designed to better understand that relationship, the doctors' contribution to it, and systemic and contextual factors in which it is embedded.
Predominantly didactic, first sessions addressed prevalence of mental distress amongst students and junior doctors and systemic and individual contributors using fictitious case examples, the aim being to normalize mental distress and challenge problematic cultural messages of invulnerability. Information regarding student and doctor-specific support services was provided to promote help-seeking and facilitate access.
Second sessions were run as discussion groups with clearly stated rules around confidentiality and respectful conversation. Permission was given for emotional vulnerability and clear boundaries discussed regarding how this would be handled safely. Emergent themes, including moral distress around involuntary treatment, feeling unwanted and 'in the way', and personal/family's healthcare experiences, were used to foster reflection upon systemic and personal issues that impacted student experience, and to facilitate peer support.
Third and fourth sessions included three 30-minute case discussions, brought by students, in which doctor-patient dynamics were salient. The facilitator's stance was to encourage reflection and, where possible, allude to themes raised in the initial two sessions. The fourth session concluded with an analysis of the group dynamics that had emerged.
RP has been widely used in medical education. This letter outlined a structured, easily replicable programme designed to address professionalism and well-being at a critical time in medical training.

Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
demand for eating disorder services in Australia. This resulted in several paediatric services revisiting the way they delivered timely and suitable interventions for anorexia nervosa. This letter describes four such responses, only one of which has been formally evaluated. 1 We also summarise important principles from service providers across Australia to whom these service delivery models were described at a workshop.
Innovative service delivery in challenging times: The themes of the four different service models, described in Table 1, were (1) increase accessibility via hybrid service delivery; (2) increase timeliness of service response by introducing a brief intervention to increase carer empowerment to action; (3) consistent educational components of interventions including parent knowledge and skills, re-nourishment and refeeding, distress tolerance and communication; (4) incorporation of guided or group intervention; (5) interventions informed by current evidence; (6) utilising lived experience across design, delivery and evaluation; (7) evaluation of outcomes.
Principles of practice identified across service providers: At the annual meeting of the 2022 Australia and New Zealand Academy of Eating Disorders (ANZAED) a workshop was conducted and facilitated by the authors with 87 registrants (13 from New Zealand), representing consumers and various disciplines across private practice, public service, and non-government organisations. Discussions were held in small groups focusing on the question: 'What principles do we need to embrace moving forward with service provision?' Five principles were endorsed. First, the importance of immediate availability of a low-resource intervention that was 'good enough'. The experience of the pandemic suggests that immediate, time-limited online/telephone connection with parents/carers is appreciated by many families, even in the absence of a detailed, multi-disciplinary, face-toface assessment. Such contact can lead to substantial improvements to those families who participate. 1 Second, the necessity of providing hybrid services to the young person with an important non-negotiable of face-to-face meetings for regular medical monitoring. Given the immense burden anorexia nervosa imposes on families, we must carefully consider which elements of service delivery can be delivered face-to-face or remotely.
Third, the immediate importance of enhancing carer knowledge and skills. The usefulness of psychoeducation, presented in digestible units, and tailored to the circumstances and context of the family, was highly valued.
Fourth, utilisation of lived experience was especially important for increasing the acceptability and uptake of services, building hope in families, engaging families in treatment, and enabling a greater understanding of the skills needed to refeed one's child.
Fifth, resources for evaluation of service delivery are essential for dissemination of what is working and what is not working so we can continue to respond flexibly in providing the best service delivery to a vulnerable client group.

Disclosure
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics Approval
Ethics approval was not required as we describe services and not evaluations of these services. Reply to Chanen (2023) 'bringing personality disorder in from the cold: Why personality disorder is a fundamental concern for youth mental health'

ORCID iD
Dear Editor, Chanen is highly critical of our paper which heightened awareness of unproven psychotherapies for adolescent borderline personality disorder (BPD). 1,2 Our aim was to protect traumatised young people from treatments without demonstrated efficacy that might otherwise cause harm. For example, Cognitive Behavioural Therapy (CBT) is commonly used for youth BPD, but traditional CBT does not address core aspects such as selfharm and affective lability. We made three main points in our original paper: However, the MOBY trial is essentially encapsulated in point 2. The trial investigated the value of psychotherapy for youth BPD and found that outcomes of a median of 23 contacts of integrated, team-based speciality BPD treatment using Cognitive Analytic Therapy as a shared model were not superior to minimal intervention (a median of 3 contacts of case management and befriending, a psychotherapy control condition that consisted of 'pleasant chats' about neutral topics and enjoyable joint activities like music and sport). 3 It is concerning that 23 contacts with a specialist youth BPD team were not superior to 3 sessions of non-specific treatment because greater amounts of specialist therapy should predict better outcomes. Given the brevity of the 3-session intervention, most of the improvements observed during the MOBY trial were probably spontaneous change and regressiontoward-the-mean over the 18month follow-up. 4 In terms of potential harms, befriending (pleasant chats and activities) was superior to Cognitive Analytic Therapy for suicidal ideation (according to the Beck Scale for Suicide Ideation over 12 months). 3 In conclusion, the outcomes, or rather lack of substantive evidence thereof, in the MOBY trial reinforces concerns about the value of psychotherapies for adolescent BPD. Chanen has not presented evidence or justified argumentation to discount ours. 1,2

Disclosure
The author reports no conflict of interest. The author alone is responsible for the content and writing of the paper.