What a wonderful and stimulating conference this year at the Gold Coast. You know it is always good when you are left pondering for days after. However, I must say that I was left feeling a little uneasy following Ivan Eisler’s keynote on the Friday. Since then I have had time to reflect further and wanted to share this with my ANZAED colleagues.

I agree with Ivan’s point, and I am sure most clinicians will that manuals can be a blunt instrument in novice hands and that they are not the panacea of eating disorder treatment.

However, I disagree with Ivan’s point that manuals are not needed by experienced clinicians or that they stunt creativity. In fact, I would say the opposite. In the past few years I have seen the difference it can make. My former team’s clinical practice used to be much more flexible and loose even though one could say the principles of FBT were applied but outcomes including treatment duration and duration of hospital stays weren’t even close to those of the RCT.

The team’s explicit commitment to adhere to the manual and have regular expert supervision has helped me and my fellow colleagues in making our interventions more targeted and refined but most importantly we saw marked significantly improved clinical outcomes.

As an ‘experienced clinician’ I have had to not only be open to new perspectives but to also unlearn some things, which at times was challenging. It has forced me to look at my practice critically, which has opened up new ways of thinking, which has allowed my and my colleagues’ clinical practice to become more refined and creative.

I would agree that strict adherence to a manuals itself does not ensure good outcomes and that in particular good supervision and team coherence and a supportive organisational context are significant.

There is certainly a tension between applying too rigidly or too loosely – or confusing flexibility with non-adherence due to lack of understanding of the model.

I think it is important in this discussion to distinguish between a clinician who considers themselves experienced in eating disorders treatment who decides to not follow the manual and a clinician who is highly experienced in the use of a treatment manual who might decide to modify the application of the manual. The risk with the former is that they remain stuck in their old ways and do not adhere to a manual out of resistance to unlearn and possibly feel deskilled whereas the clinician truly experienced in the delivery of the treatment model will more likely be able to make an informed judgement when creativity and flexibility might be indicated.

I worry that inadvertently Ivan’s comments may have be taken wrongly and we will go backwards to a time when essentially clinicians did as they pleased depending on their theoretical orientation/ training and preferences under the guise of ‘being flexible’ and ‘knowing what they are doing’.

Personally I believe the key is using the manual (any manual) alongside expert supervision. One might say that developing and testing the manual is the science but the execution of the interventions in clinical practice is the art.