The Story Behind My Career
(This page is in progress)
It will probably be evident from the Brief Biography (in the Career page) that I have had a successful and productive career, and one which has had a positive impact on many peoples’ lives. This raises the question of how did it come about, especially given the unpromising start.
Here is my account of what happened. [I apologise for the fact that I am still in the process of writing it … and will be for some time.]
The Early Years (1969-1977)
An Unpromising Start
I went up to Oxford in 1969 and, I am embarrassed to say, I did not enjoy either of my degree courses. I found Physiology dull and Medicine did not excite me either. I was more interested in the patients than their diseases. As I "rotated" through the various specialities as a medical student I found myself eliminating each one as a future career.
First encounters with psychiatry - Near the end of the rotation came Psychiatry, a speciality I viewed with scepticism. Despite this, I was immediately won over by the subject and by those who worked on it. The psychiatry department was led by Professor Michael Gelder, an extraordinary man who was to have a profound influence over my future career. He was a world leader in researching psychological treatments and this was a major focus of the department. Alongside Michael Gelder was John Bancroft, a leading researcher on sexual problems and sex therapy. A particularly attractive feature of the department was its active engagement with medical students. I was allowed to attend the departmental lectures and seminars; I was given a patient to treat (a baker with a phobia of rats); and I was allowed to join a group being trained in sex therapy. By the end of my placement I was hooked, and I carried on being closely involved with the department throughout the remainder of my time as a medical student.
Training in Edinburgh - Towards the end of my medical student training, I approached Michael Gelder about how best to pursue a career in psychiatry. He said I should leave Oxford since I was already familiar with Oxford psychiatry and that I should either go to the Maudsley in London or go to Edinburgh where there was an excellent department led by Professor Robert Kendell. I chose Edinburgh and it proved to be the ideal place to get a sound grounding in psychiatry. The Royal Edinburgh Hospital was a well-run, busy hospital serving the whole of Edinburgh (not all of which is well-heeled) so one say a wide range of problems and Robert (Bob) Kendell himself taught all the main subjects. This was an enormous privilege as he had an encyclopaedic knowledge of the field coupled with extraordinary lucidity. His particular interest was in descriptive psychopathology (the accurate description of abnormal mental states) and the definition and classification of mental disorders. Like Michael Gelder, Bob Kendell was to have a lasting influence on my career.
On completing my core training in psychiatry (during which I spent six months working beside Ivy Blackburn, one of the pioneers in cognitive therapy research), I was appointed Lecturer in Psychiatry, a post that had time allocated for research. This raised a problem: What was I to research? During my training I had been a therapist in a sex therapy trial and had completed a research project on the sexual problems of diabetic men (both under the supervision of John Bancroft who also had moved up to Edinburgh) but this field didn't engage me, although I was intrigued by psychological treatment research. I needed something of my own to study. That "something" shortly fell into my lap.
Right Person at the Right Time (1977-1981)
The Emergence of Bulimia Nervosa
My first case - One of my responsibilities as a Lecturer was to participate in the Professorial Unit outpatient clinic. One week Professor Kendell asked me to see a referral who was said to have anorexia nervosa. I was pleased about this as I had never seen a case. The person in question was a student in her early 20s. She was distressed, tearful and highly self-critical. She gave a clear description of extreme dieting, frequent self-induced vomiting, and herintense dislike of her body. She seemed to have many of features of anorexia nervosa bar a critical one: she was not underweight. I was perplexed.I explained this to Professor Kendell who suggested I hadn't weighed her correctly! He then interviewed her himself and emerged as perplexed as me. The consultation ended with him telling me to do two things:
Read the world literature on people like her and report back next week
"Get her better"
Both were tall orders. This was 1977, well before the internet, and there was no easy way to scan the world literature, let alone in seven days. Nevertheless I tried but came up with virtually nothing. As for the second task, this was precisely the challenge I was looking for. As has been remarked subsequently, I was "the right person at the right time" since I had some knowledge of psychological treatment development and I had time to devote myself to the task.
I began to see the patient regularly and gradually got to know her and her problems better ... but her normal weight remained a mystery. Based on her account of what she was eating, she should have been markedly underweight. In the end I decided to simply ask her why her weight was normal despite her eating so little. This question caused her immense distress, but it provoked her to disclose what she had been hiding from e. She was having repeated "binges" in which she ate huge quantities of food. These occurred almost every day and were a source of great shame. Now her weight made sense. Even though she vomited immediately after each episode, I was certain she must be absorbing quite a bit of what she was eating.
More cases - Remarkably, three weeks after this first patient was seen a second one arrived and she had an almost identical eating problem. This patient's difficulties were more longstanding and she also had an alcohol problem, but in all other respects the two patients closely resembled each other. Hard though this may be to believe, a third, very similar, patient was referred a few weeks later, the result being that I now had three of these patients to "get better".
Devising a Treatment
Tackling the binge eating - Initially, my efforts focused helping these patients regain control over their eating as this was their main, if not sole, goal. Two processes seemed to be responsible for their binges. The first was their reaction to breaking any of their dietary “rules”, their response being to give up and overeat. The second was their use of overeating as a means of coping with unpleasant thoughts and feelings. Binge eating was distracting and it calmed them down. These observations suggested that treatment should discourage attempts to adhere to rigid dietary rules while also enhancing their ability to deal with day-to-day difficulties. The patients agreed with this strategy as it made sense to them but, disappointingly, it proved to have little or no effect on their binge eating.
At the same time I studied the literature on overeating in obesity and ended up concluding that I should also address these patients' eating pattern; that is, the timing of their eating. I thought I should help them eat at regular intervals and not between. This proved to be a turning point. In each case adopting a pattern of "regular eating" resulted in a sharp drop in their frequency of binge eating, and once this happened they were more able to address their dietary rules and life difficulties.
Recruiting further cases - Meanwhile I enquired whether the other teams at the Royal Edinburgh Hospital were encountering similar patients. They were, and I volunteered to take over their care. The upshot was that by 1978 I was treating eight cases of this “new” eating disorder.
The importance of shape and weight - With hindsight, it is extraordinary that I was paying almost no attention to these patients' concerns about their shape and weight. This changed in the summer of 1978 as a result of one of my patients returning from a hitchhiking vacation with an extremely painful back. On enquiring about the cause she reported that her weighing scales resulted in her rucksack being impossibly heavy! The penny then dropped. These patients place inordinate importance on controlling their shape and weight, and that it was this, of course, that drove their dieting. From this point onwards, these concerns were a major focus of treatment.
By the beginning of 1979 I had developed a reasonably standard treatment "protocol" with a specific strategy and sequence of procedures. The treatment was designed to disrupt the main processes that appeared to maintain bulimia nervosa. I now needed to apply this protocol to a new series of patients. However, there was a problem: the disorder didn't have a name which made it difficult to communicate with colleagues and patients. Fortunately, this difficulty was solved a few months later.
Russell's Paper on "Bulimia Nervosa"
In August 1979 I was amazed to read an article describing patients just like mine. The paper was titled "Bulimia nervosa: an ominous variant of anorexia nervosa" and its author was Professor Gerald Russell, one of the world experts on eating disorders. In it he described 30 cases that he had encountered over the previous eight years.
The paper was outstanding in many respects, not least in its identification of an apt name for the condition. However, two of Gerald Russell’s suggestions did not ring true to me:
First, he implied that bulimia nervosa was uncommon. This seemed unlikely to me as I had by then seen almost as many cases as he had, yet I was completely unknown. Furthermore, I was struck by the fact that many of these patients had kept their problem secret for many years. It seemed to me that bulimia nervosa could be a common, but hidden, problem.
Second, he stated that the disorder was "intractable" (oddly, this word was misspelt in the paper). It being intractable was not my experience at all. At least half my patients appeared to make a complete response and many of the others improved substantially.
Russell's paper catalyzed interest in research. I wanted to see whether bulimia nervosa was more common than he thought, and more importantly, I wanted to put my treatment to the test. Accordingly, I went to Bob Kendell to seek his advice. He was encouraging and very clear. He said I should return to Oxford as this was the place to conduct such work. He also added that I was very unusual in that I had "vision". I didn't think about this at the time but now, 30 or so years later, I think he may have been right.
Moving to Oxford was not straightforward as I needed a job! Luckily a NHS post at Littlemore Hospital became available about six months later. In the meantime I set about seeing whether bulimia nervosa was more common than Russell thought by I enlisting the help of Cosmopolitan.
The Cosmopolitan Study
The challenge I faced was how to detect a problem that was kept hidden. Somehow I needed to get in direct contact with them ... I needed to “advertise” for them. My solution was to write to Cosmopolitan Magazine and ask if they would publish a request for readers to write to me if they thought they had the disorder (having outlined its core features). The magazine agreed and my request was published in the April 1980 issue (see below).
I was taken aback by the scale and nature of the response to my "advert". With weeks I had received over a thousand replies. With the help of my wife (whose help I needed as I had no research assistance), I sent a 170-item questionnaire to the first 800 respondents. Over 80 percent replied in full, and of them 499 clearly fulfilled Russell’s diagnostic criteria for bulimia nervosa.
It was extraordinary how closely these 499 respondents resembled my cases and those of Russell:
All were women (admittedly it was a women’s magazine)
Their average age was 24 years
On average they had been binge eating and vomiting for more than four years
Most had a weight in the healthy range
They had high levels of eating disorder features and symptoms of anxiety and depression
Many wrote long moving letters requesting help and most expressed surprise and relief that they were not the “only one”. Despite this, fewer than a third had mentioned the problem to their doctor, their explanation being guilt and shame. These findings (reported in the British Medical Journal in 1982) clearly supported my suspicion that bulimia nervosa was no rarity, and they reinforced my view that there was an urgent need for a treatment.
The BBC Study
Two weeks after the Cosmopolitan request was published I received a phone call from the BBC asking whether anyone had responded. I explained that I was being inundated with replies and I outlined the nature of them. The upshot was that the BBC produced a documentary on bulimia nervosa which was broadcast in January 1981 by which time I had returned to Oxford.
In the BBC programme bulimia nervosa was described in detail (including a mention that men could be affected) and at the end of the programme viewers were invited to write to me if they thought they had the eating problem. Again, there was a dramatic response: indeed, Littlemore Hospital switchboard was blocked for two days and I had my own postal delivery for almost a week! (To my embarrassment, another result was that I was photographed by the local newspaper standing in front of Littlemore Hospital with the caption beneath reading “Dr Fairburn in front of his clinic.” This did little to endear me to my new Oxford colleagues!)
In total over 6,000 people responded to the BBC programme. I sent the first 1,800 questionnaires similar to those used in the Cosmopolitan study and again there was a high response rate. There were two main findings:
The respondents who met diagnostic criteria for bulimia nervosa closely resembled the Cosmopolitan cases but were slightly older (average age 28 years).
Just 2% were male
As before, the majority thought that they needed help, reinforcing once again the need for an effective treatment.
Fairburn CG, Cooper PJ. Binge-eating, self-induced vomiting and laxative abuse: a community study.
Psychological Medicine 1984; 14: 401-410.
My First Grant Application
I returned to Oxford in the summer of 1980 and sought an appointment with Professor Gelder. I told him about my work and my desire to evaluate the new treatment, and described a plan for doing so . (On Michael’s retirement 16 years later he told me this was the only time in his entire career that someone had come to him with an entirely new, fully worked up, programme of research.) My question was how to get the funds needed. His response was immediate. Given my modest track record (no PhD and no publications) I should apply for a three-year MRC project grant and the deadline was in six weeks! This was great news as far as I was concerned and, under the guidance of Dennis Gath, I submitted an application on time.
Five months later feedback arrived. The grant committee thought the research was interesting but none had heard of the disorder! They had therefore sought the views of an outside expert (presumably Professor Russell) who also liked the research but had two reservations: first, it would be difficult recruiting patients as the disorder was uncommon; and second, they patients were unlikely to cooperate with the research. Neither reservation seemed warranted to me. By then I had data from the Cosmopolitan study showing that bulimia nervosa was no rarity, and my experience treating these patients indicated that they welcomed helping with research. I responded to the MRC along these lines and three months later I learned that the grant had been awarded!
Chapter Three - The Bulimia Nervosa Years (1981-1999)
The first trial was a small one involving just 24 patients, 12 of whom were to receive my treatment (now labelled CBT for bulimia nervosa or CBT-BN, and outlined in a paper published in 1981 - shown below). The other 12 were to receive an alternative form of psychotherapy, one which was designed to be as plausible as CBT-BN and involve the same amount of therapist contact, but without what I viewed as its active ingredients.
The grant paid my salary and the salary of a research assistant whose role was to assess the patients before and after treatment, and at follow-up, without knowing which treatment they had received. Marianne O’Connor applied, already a member of the department, and her wonderful manner and quiet efficiency made her perfect for the post. (She continued to work with me for the next 36 years!) A third team member was also needed but this had to be a volunteer as their involvement was not covered by the grant. Their role was to join me in treating the patients. Clearly it was essential that this person was a skilled, research-oriented, therapist. I was therefore extremely lucky that Dr Joan Kirk volunteered as she was one of Oxford's most highly respected clinical psychologists.
The Need for a Measure
With the staff in place, the study started in September 1981. What was immediately clear was that there was a need for a rigorous measure of eating disorder features as the available ones were crude and focused primarily on the features of anorexia nervosa. Devising such a measure was not going to be simple as it would involve specifying and defining the main features seen in people with an eating disorder, and then working out how to assess them. Again I was extraordinarily lucky. Zafra Cooper, a friend of a friend, was training in clinical psychology and she thought work of this type would make a great dissertation. As it turned out, it would have been enough work for half a dozen dissertations!
Zafra and I worked assiduously and meticulously on this measure for several years. It was a painful process for both of us with each of us nitpicking each other's suggestions. She was helped by her background in philosophy and I benefited from my time with Bob Kendell. The end product was a sophisticated semi-structured interview, the Eating Disorder Examination (EDE). Thankfully, the time and effort were well spent. Even today, the EDE is viewed as the “gold standard” measure of eating disorder features. (More widely used is its self-report version, the EDE-Q.)
Cooper Z & Fairburn CG. The Eating Disorder Examination: a semi-structured interview for the assessment of the specific psychopathology of eating disorders. International Journal of Eating Disorders 1987; 6: 1-8.
Fairburn CG & Beglin SJ. Assessment of eating disorder psychopathology: interview or self-report questionnaire? International Journal of Eating Disorders 1994; 16: 363-370.
Running in parallel with these developments was my exposure to the outside world of research. Bob Kendell very kindly arranged for me to meet Gerald Russell who was a delight. He seemed very interested in my work despite the fact that it contradicted the main conclusions of his 1979 paper, and he arranged for me to speak at a forthcoming international conference on eating disorders. This took place in Toronto in the summer of 1981, just before the trial started. For me, it was a momentous occasion as I met all the famous “names” in the field. Apparently, I made quite an impression as I unveiled both the treatment results (which were about to be published) and the Cosmopolitan findings in one 20-minute talk. I was 30 years old.
I had another remarkable encounter that summer. Michael Gelder told me that a friend of his was visiting who was most interested in my work. The friend was Albert (Mickey) Stunkard, a world leader in obesity research. Mickey and I spent an afternoon together walking around Oxford. He was extraordinarily enthusiastic ... he even clapped at times! He wanted to know all about my patients and was especially interested in their binge eating. We parted friends and with me being invited to a major conference in New York and to visit his team in Philadelphia. Later, I discovered the basis for Mickey’s excitement. He was the first person to describe “binge eating” (in 1959) and he had remained passionately interested in the topic ever since.
The third key person introduced himself in a strange way. Almost two years into the trial a letter arrived out of the blue. It was from G Terence (Terry) Wilson, a world leader in psychology and psychological treatment research. In this letter he asked for my view on a paper that had recently been published, the implication seeming to be that he thought the findings were implausible. This put me in a dilemma. I shared his scepticism, but was it appropriate to state this in a letter (especially to someone I had never met)? After much agonising, I replied in cautious terms (but apparently it was obvious what I really thought!). This exchange created a bond between us. Soon afterwards Terry invited me to visit him at Rutgers University and ever since he has been a mentor, colleague and good friend.
The Next Step
Towards the end of 1983 I went to see Michael Gelder once more. Everything was going extraordinarily well and I couldn’t be busier, but my funding ran out the following September. What was I to do?
Michael came up with a radical suggestion. The Wellcome Trust, a major funder of health-related research, had launched a new scheme designed to provide longer-term support for leading biomedical scientists. He suggested that I apply. It seemed to me that I wasn’t the type of person that they were looking for but I went ahead and applied for funds to support a second trial. Three months later I was called for interview.
The interview was intimidating to say the least. It was held in a grand building in central London and the interview panel were all top scientists. There was no overlap whatsoever between their fields of expertise and mine. The interview was a strange affair. It was formal but friendly (“gentlemanly” might be a better term) and everyone seemed inordinately pleased if I kept talking, perhaps because as it took the pressure of them to ask me appropriately testing questions. I left the interview feeling that it had been a waste of everyone’s time.
It therefore came as a great surprise to learn later that week that I had been successful. I had been awarded a Wellcome Senior Lectureship, a highly prestigious award that would fund both me and my research. I subsequently discovered (at the annual meeting of WSLs) that virtually all the others appointed were basic scientists and none had any overlap with my type of work. With hindsight, I suspect my success can be attributed to those who wrote letters of support (probably Gelder, Russell and Stunkard). Whatever the explanation, the appointment was propitious as the Wellcome went on to fund me and my research for the rest of my career!
TO BE CONTINUED