‘It’s a privilege to work at Great Ormond Street, but it brings responsibilities’

We meet Dr Rachel Bryant-Waugh.

Dr Rachel Bryant-Waugh tells Ian Florance: ‘I do feel hugely committed to Great Ormond Street . You get to meet extraordinary families and children and identify patterns of behaviour in often very complex difficulties. It’s a privilege but that comes with a responsibility to communicate what you learn to other people who might find it helpful. That’s where teaching, influencing policy and writing come in.’

Great Ormond Street Hospital is buzzing when I arrive in the early evening to interview Rachel Bryant-Waugh. It’s an energising place, set in one of these villagey areas in the centre of London. Rachel is leaving the Feeding and Eating Disorders Service at the hospital, with which she has been associated for almost 35 years. She has a fascinating story to tell with, I suspect, new chapters to be written.

‘In many respects I’m my father’s daughter. I’ve inherited his desire and liking for being proficient in what I do. I’m organised.’ Her father moved with the family from Surrey to the Phillips head office in Eindhoven when she was 11. ‘I was useless and cross during my first year in Holland. I was taught in Dutch at a very progressive school, which had a very different culture from Sutton High School for Girls! Perhaps being in a different place, negotiating a different language was what interested me in psychology in the first place. I would have said that I was “interested in the human experience”.’

Rachel wanted to go to a Dutch university – ‘I had a Dutch boyfriend apart from anything else’ – but the only way of doing that was to take dual nationality. ‘I’d describe myself as pretty defiant, so I went to live with a lovely family in Paris and studied history of art.’

But Rachel finally made it to Sussex where she went on ‘a wonderful, maverick, seminar-based four-year BSc course in Human Sciences. I found it difficult at first: there was a real sense of dislocation. In my first biochemistry lecture I had to turn to ask my neighbour what sodium was, as I only knew its name in Dutch. However, when a tutor asked, “Now what do you think?” and encouraged critical thinking I realised I was in the right place. The course covered a huge range of topics from biochemistry and genetics to images of childhood, and I was so interested in many of them that there was a real danger I’d lose focus. But, to repeat, I’m like my father in my desire to master things – if I think I can do something I don’t like to deliver second best. I was also interested in development and children. My mother ran a nursery school and my sister is a teacher, so it runs in the family. And of course, Sussex was quite a radical, exciting place. There were lots of sit-ins. And as students we were hugely influenced by Ivan Illich, Thomas Szasz and the whole anti-psychiatry movement. I registered for a DPhil at Sussex in developmental psychology, and spent a year doing various jobs.’

Bright but... rather snooty!?
Rachel got her first job at Great Ormond Street in 1983. ‘So, I’ve worked here, on and off, for 35 years. I was initially a nursing assistant – that’s what graduate jobs were called back then. I remember that Bryan Lask who interviewed me wrote in his notes that I seemed “bright but... rather snooty”. I started work in the child psychiatry inpatient unit where there were a couple of children who had anorexia nervosa. This was in the 1980s. Adult bulimia was just being recognised, but there was precious little work on childhood eating disorders. I watched Bryan talk to the children and afterwards asked him why he was so rude and bossy towards them: I was questioning everything at that phase. Bryan answered, “I don’t know why.” That led to a dissertation on “Childhood onset anorexia nervosa: Presentation, course and outcome”.’

I had noticed that one of Rachel’s many interests is the children of mothers with eating disorders. Was this an early area of study? ‘In 1982/83, when I was in my first year of doing my part-time postgraduate degree and before I had decided what to focus on, I went on an introductory course at the Institute of Family Therapy in London, so I was interested in the area even then. Later I spent some time setting up the Southampton adult eating disorder service and worked with mothers who attended the clinics. They often feel very isolated, and there are a number of issues – body-hatred, bottle vs. breast feeding, implications for the child if the mother is not receiving enough nutrients, among many others – which I began to be interested in.’

Rachel started a master’s in clinical psychology in 1985 and... by this stage my notes suggested that Rachel was involved in about four or five major courses and jobs. I asked her if I was getting the chronology wrong. She answered with a smile. ‘I tend to do that. So, in 1985 I got married on the Saturday and started my clinical training on the Monday while still doing my DPhil. In January 1988 I had my first child, having completed all my clinical training requirements, spent the subsequent months finalising my DPhil thesis and MSc dissertation and submitted both ready to start work back at Great Ormond Street in the June. I like things to be neat, but that was a bit excessive!’

In 1987 Rachel was on a placement at the Middlesex Hospital as well as in the early stages of her pregnancy. ‘I worked with the HIV team, and I was there when Princess Diana shook hands with an AIDS patient. It’s difficult to remember what an important act this was. It had the effect of challenging stigmas in society and was a phenomenally powerful thing for her to do. Being with so many dying young men who were battling social exclusion and prejudice had a profound effect on me. The HIV clinic was an extraordinary place to work offering compassionate care to patients who had suffered social exclusion and prejudice.’ Rachel had another experience of Princess Diana’s ability to cut through prejudice. ‘I was on the platform when she opened our conference on eating disorders, held at Kensington Town Hall, and spoke passionately about young people with eating disorders. It was widely held to be rooted in her own experience. She had made private visits to our eating disorder clinics before that.’

Still a lot to do
At the end of the 1980s, Rachel and Bryan Lask set up the first UK programme dedicated to treatment of childhood eating disorders. This focus allowed them to identify a range of clinically significant eating difficulties, all with serious consequences for everyday functioning, and negative implications for health and development. These included what was then known as pervasive refusal syndrome – a refusal to eat, drink, talk or even walk – but without the anorexic’s obsession with weight. This focus on childhood onset feeding and eating disorders is one of the achievements she’s proud of – what are some of the others?

‘Well, I suppose I’d say I was “content with” certain things I’ve done rather than “proud of” them. Co-writing Eating Disorders: A Parent’s Guide is an example. I wrote it after having my third child by getting up at four every morning and writing for two hours. But the real reason I mention it is that it seems to have helped so many people. It’s not an academic book but tries to do exactly what it says in the title. It’s good to know that you’ve affected people’s lives for the better.

‘I think I’ve had a part in the increased recognition that children can develop eating disorders. There’s still a lot to do – children’s mental health has been marginalised, especially primary-school-aged children. But I’m very positive about the future here.’

Rachel says she has also really enjoyed the eating disorder work group that informed the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). ‘Of course, children don’t present with precise diagnostic categories, but unless there’s some agreement about the commonest patterns, different people will interpret a presenting child’s condition in very different ways – and then you get trapped in terms of taking research forward. I was invited to join the working group by the APA [American Psychiatric Association], having previously worked on some NICE guidelines, and they were a fantastic group – insightful, compassionate, thoughtful, collegiate. We had sufficient evidence to define a diagnostic category, but these categories are never final. They are hypothetical constructs that need constant revisiting. They’re helpful if you see them for what they are. They shouldn’t pathologise anyone but provide patterns and underpin discussions about if, where and how far a particular individual fits. They provide a shared language for person-centred discussion.’

Rachel also mentions the additional money invested in community services for child and adolescent eating disorder services, pioneered by Norman Lamb and announced by Nick Clegg. ‘I was national clinical adviser on how the money should be spent. It’s early days yet, but when I think back to what things were like before this, it’s changed a lot – for the better’

Rachel conducts research and gives talks and lectures, but her most recent role has combined leading her multidisciplinary team as Senior Consultant Psychologist, and a significant caseload. ‘I like to be emotionally engaged in my work. I’ve always tried to foster a strong multidisciplinary team with a supportive culture. Of course, even Great Ormond Street has its challenges – specialists at the top of their profession can be difficult to work with, and NHS policies create tensions.’

What will you do after you leave, Rachel? ‘Honestly? I don’t know! But I’m not stressed about that. I’ll still work in the same field and I want to push things forward. I have my own personal shed and I do have some writing plans – to include some that are not academic…’

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