How many professionals that treat eating disorders have a personal history of struggling with an eating disorder? It is a crucial question to ask (and answer) because there are important implications for patient treatment and for the health of the afflicted professionals. It is true that many (or most?) individuals who go into mental health do so because of personal experiences–whether due to their own personal history or the experiences of a loved one–so it is useful to ask, just how common are eating disorders among ED treatment professionals?
This is the question that Nicole Barbarich asked in a survey mailed to 823 members of the Academy for Eating Disorders.
Barbarich developed a 14-item self-report questionnaire that assessed everything from basic demographics to personal eating disorder history and their employer’s hiring policies. Out of 823 potential participants, 399 completed the questionnaire.
SUMMARY OF MAIN FINDINGS
Demographics of Survey Responders
- 81% were females, 19% were males
- Average age: 44 for females, 49 for males
- Primary employment area: 47%, individual therapy; 34% in outpatient programs; 11% in inpatient programs (smaller %ages in PHP/IOP, group therapy, nutrition, medication management, other)
Eating Disorders
- Lifetime prevalence of an eating disorder was 27%
- Among females: 33%
- Among males: 2%
- Type of eating disorder (~35% had more than one)
- Anorexia nervosa: 47%
- Bulimia nervosa: 50%
- Binge eating disorder: 24%
- Subclinical ED: 17%
- Duration of ED: from 4 – 372 months (31 years), average: 115.5 months (~9 1/2 years)
Treatment & Relapse
- 64% reported having received treatment
- 56% individual therapy; 30% group therapy; 18% medication; 12% outpatient; 11% nutrition therapy; 10% inpatient/residential; 7% PHP/IOP
- 27 (out of 97, as 12 didn’t answer) experienced relapse after entering the field as a professional; prior history of purging-type AN was associated with a significantly higher risk of relapse
Employment
- 39% reported that their employer was aware of their ED history (about the same number didn’t, and 23% were self-employed in private practice)
- 33% of those who reported their employer knew about their ED history experienced a relapse while working in the field (versus 16% of those whose employers didn’t know, though the difference is not significant)
- Hiring practices of participant employers: 33% hired recovered staff but history didn’t affect employment decisions; 6% actively hired recovered staff versus 9% that preferred NOT to hire recovered staff; 27% were either not aware of policy or their employer didn’t have a policy
The prevalence of anorexia nervosa and bulimia nervosa in adolescent and young adult females is about 0.5-1% and 1-2%, respectively. In this study, the prevalence was 13% and 14% for anorexia and bulimia, respectively. In total, 33% of female and 2% of male ED professionals surveyed had a prior history of eating disorders.
Of course, only 50% of AED members responded to the survey, and it was just a survey (not a validated questionnaire), so it is hard to know how applicable these findings are to ED professionals in general, but, there’s little doubt that eating disorders are overrepresented among professionals in the field.
These findings raise a lot of questions:
- What are the advantages and disadvantages of having clinicians who have a personal ED history?
- Are clinicians with an ED history better/worse (more/less effective) at treating patients, or the same? Does it even matter?
- What about self-disclosure? Good thing, bad thing, depends?
- How should treatment centres, for example, deal with relapses? What if relapses occur in a private practice setting?
- Is there a way to know which professionals are at a higher risk of relapse? (In this study, they were: longer duration of ED, AN-purging type, and history of more than one ED. But, in other studies found different predictors of relapse.)
Admittedly, some of these questions have been explored in studies since this paper was published, mostly using qualitative research methods (here, here, and here). I’ll do a post in the future about the possible advantages and disadvantages of ED clinicians with personal ED histories as it is definitely an important and interesting topic to think about.
As for now, I’m curious to hear what you think–as patients, parents, friends, clinicians, and researchers–about this issue and the implications. Thoughts?
References
Barbarich, N. (2002). Lifetime Prevalence of Eating Disorders Among Professionals in the Field Eating Disorders, 10 (4), 305-312 DOI: 10.1080/10640260214505
This is a very interesting article, and an issue that I’ve considered in my own life. I’m firmly in recovery and wish to work in mental health. I’m not sure on a specific area, and have kept treatment of eating disorders as a potential career. However, this is not a ‘goal’ for me. It is a consideration that, if I feel I can do it then great, and if I feel that I can’t do it, then that’s fine too and at least I’ve had the self-awareness to know.
It’s a double-edged blade. On the one hand, a clinician who has had personal experience of an ED has a greater understanding of the condition itself. Every patient is different, but there is some level of empathy there that a clinician without an ED history can’t have (though I’m not saying this is a flaw for non-ED history clinicians). As such, there could be a greater understanding of the daily struggles faced by patients, perhaps helping treatment outcomes, or at least rapport with the patient. Conversely, there could be a greater level of frustration or distress at seeing someone else suffer the way they suffered previously, and being responsible for their care and treatment.
The other risk is, of course, relapse, as the study mentioned. I know that in myself, there would be a potential for relapse if I was surrounded by eating disordered individuals all day. I’m firmly in recovery and want to stay that way, so I would be cautious about working with ED patients. It’s definitely not something I would do soon. It would have to be something I was as confident as possible that I could handle, that I was stable in my recovery to the point of being able to resist the triggers that would come with working in that environment.
“On the one hand, a clinician who has had personal experience of an ED has a greater understanding of the condition itself. Every patient is different, but there is some level of empathy there that a clinician without an ED history can’t have (though I’m not saying this is a flaw for non-ED history clinicians). As such, there could be a greater understanding of the daily struggles faced by patients, perhaps helping treatment outcomes, or at least rapport with the patient.”
See, I’m not sure this is necessarily true. Ironically, I felt much more understood and at ease among clinicians who haven’t experienced eating disorders than those that have. My sample size is very small, so it could easily be unrelated to their ED history and more to do with their personality, but, I don’t think it is necessarily true. Someone with decades of experience coming at the issue with an open mind might be much more suited for counselling/therapy than someone whose had specific ED experiences and isn’t open to other views, choosing to view the patient through their narrow lens, based on their personal experiences.
It is hard to untangle whether the differences are just differences are due to ED history, in my case, anyway, but that’s certainly my feeling.
I’ll bite! Pun not intended…
I am a trainee counsellor/therapist with a history of originally EDNOS with periods of BN and then a long stint of AN at the end, all spread out over 12 years, with my recovery beginning in early 2009. One of my placements as a student is with a local charity which provides support to women with eating disorders and disordered eating. I have two clients there – one who seems to be more on the disordered eating side of things, one who is really quite unwell with anorexia. I am under no illusions that I can “cure” her just by virtue of understanding what it’s like, but the services in my area are very patchy and I tend to feel that my support is probably better than no support. I mostly work with her using motivational interviewing techniques (great for working around ambivalence) and psychoeducation, underpinned by person-centred principles.
I guess the advantage of having had an eating disorder myself, and having been ‘around’ people (mostly online, hence the ”) with eating disorders for a very long time, is that I am very open minded about how different individuals may experience EDs. If a client really struggles with body image, we can work on that. If they have never felt fat in their lives and it feels more OCD-like to them, we can work on that too. I won’t tell them they “can’t possibly be eating that much because you always digest 1/2 the calories of a b/p” or accuse them of being difficult if they are scared of change. I don’t subscribe to the common myths about eating disorders, and I am pretty agnostic on cause. I personally felt like my anorexia was driven by malnutrition, but the way I ended up malnourished in the first place was mostly related to environmental stressors and the weird way that starvation makes me feel nice and numb (which has got to be a biological process, but I studied physics before counselling rather than biology, so…), so I’m not about to tell anyone that their ED is *about* any one thing (not wanting to grow up, control, abuse, blah blah blah…). The disadvantage of clinicians who have had EDs themselves is that they often seem to think that their narrative is the only one that counts, so if they found assertiveness training to be the way out of their eating disorder, that’s what everyone with an ED needs, or if they were abused, that means anorexia is always caused by abuse, etc. That mindset really drives me crazy.
The downside of having ME as a therapist is that I am only human, and I believe that under certain circumstances I would be vulnerable to relapse. I get a bit weird about eating if I’ve had a stomach bug or if I’m under a lot of stress. If I relapsed I’d have to put myself out of commission until I was on top of it again, because otherwise there would be too big a chance of me passing on my own disordered thoughts to my clients, or maybe not being able to see when my clients were in trouble because I was trying to pretend to myself that ED behaviours weren’t that big a deal. That could be really dangerous for everyone concerned. I don’t think anyone with an active eating disorder should be seeing eating disordered clients.
I always err on the side of caution when it comes to self disclosure. I wouldn’t tell anyone with an eating disorder that I’d had one too unless they somehow unearthed stuff online about me and confronted me with it. I’ve done a lot of activism-y stuff around eating disorders and rape, and although I’ve done my best to sever some of those links (there’s no mention of my surname or the organisations I train with/have my placement at on my blog, my photographs are password protected and you can’t see me on Facebook unless I find you and add you as a friend, or if you’re a friend of a friend. Which you are Tetyana!), it’s still very possible that this will happen one day. Ultimately I’m there as a counsellor, not a peer support, so I’d have to just bear that in mind, and avoid being drawn into discussions of my own history, while obviously not doing anything daft like lying. I would answer the question, but I would remind the client of the boundaries of our sessions too. Otherwise I wouldn’t disclose my former ED. There’s no need for it, I can show I understand the client in other ways.
Lots of people have very strong opinions on this – either therapists who have had EDs themselves are obviously better or obviously a liability – but I really think it depends on the individual. I hope I would be insightful enough to know when I am safe to practice and when I am not, and if I wasn’t, I’m damn sure my girlfriend would tell me, because I can’t be an hour late for dinner without her worrying 😛
Blimey, that was longer than intended! Sorry!
The funny thing is, the only times I’ve been told that ED’s are about this or that, and felt invalidated, was by individuals with ED histories.
“The disadvantage of clinicians who have had EDs themselves is that they often seem to think that their narrative is the only one that counts, so if they found assertiveness training to be the way out of their eating disorder, that’s what everyone with an ED needs, or if they were abused, that means anorexia is always caused by abuse, etc. ”
Yeah, I’ve witnessed this, and it was mega annoying.
“Otherwise I wouldn’t disclose my former ED. There’s no need for it, I can show I understand the client in other ways.”
Exactly. I think that’s an important point. Disclosure in and of itself doesn’t necessarily mean understanding, it is better and more important, to show it in other ways. I think.
I definitely know my opinions on this are completely based on my super limited experiences, but of course, it is hard to completely ignore them, too.
Hopefully clinicians working in EDs don’t have the myths that non-ED clinicians and healthcare workers have, though, there are always bad apples, everywhere.
Just read this briefly before class, but a couple thoughts –
1) I’d be interested to know what the stats are for lifetime prevalence of psych disorders in mental health professionals in general, for comparison. Are the rates for EDs higher, lower, about the same? My money’s on the latter. (Even in research, people who’ve had personal experience with the issue themselves or in their family seem much more inclined to focus on that issue – someone in my lab used the term “MEsearch” the other day, which I thought was pretty funny/apt.) The issues raised above may not be unique to EDs and ED professionals.
2) Given that a large part of the health & mental health field is moving towards adoption of the peer counselor model (I know the US Veteran’s Association has a program and is actively hiring, ditto several hospitals I know of w/r/t schizophrenia and other severe mental illnesses AND for issues like diabetes, heart attacks), does that change how we view the phenomenon of recovered (from anything) people going into that line of work?
I think it depends what disorders. Addiction, probably high, but something that’s potentially more severe/long-term, like schizophrenia, probably lower (but I bet still higher than in the normal population, because there are many schizophrenic patients that are able to work and lead successful lives, of course).
Yeah, definitely agree on the research part. I’m weird in that I don’t want to do ED research at all, and my science interests are so totally removed from mental health or anything relating to cognitive functions. Depends what field people are in, too.
According to this blog post on addiction counselling, seems like there are fewer and fewer ex-addicts in the field (http://addiction-dirkh.blogspot.ca/2009/07/changing-face-of-addiction-counseling.html).
I don’t know how it changes it, honestly–I don’t even know how “we” view it.
Katie articulated just about everything I could mention re: pros/cons. I feel conflicted on the issue. On one hand, I’ve had clinicians (particularly nutritionists/therapists) who have obviously had a history of ED, and that carried over – for example, if a nutritionist was maintaining a minimally-healthy or sub-healthy weight, that a) sets a poor example, and b) I felt potential for judgement, even if not conscious, if my weight did not behave similarly through binging or normalization of eating, or my goal was to go above that bare minimum target.
On the other, there is a lot of discourse, particularly among some parents/caregivers, that imply that once ED’d, a person with an ED history is ALWAYS “mentally ill” and will never be able to move beyond their own experience into a professional perspective on the issue. I give a heavy side-eye to anyone fresh from treatment or new to recovery whose goal is to go right back into that ED treatment world and become a dietician or other professional specializing in EDs, because I do think that is a common way – even if not intentional – to hold on to the last vestiges of ED. For SOME. But I’ve also known some amazing, compassionate, intelligent clinicians who had a history of ED but were able to let that inform their work appropriately (not conflating client with self, in strong recovery and modeling healthy behavior, no inappropriate disclosure – the latter is a big one and a real danger.)
“I give a heavy side-eye to anyone fresh from treatment or new to recovery whose goal is to go right back into that ED treatment world and become a dietician or other professional specializing in EDs, because I do think that is a common way – even if not intentional – to hold on to the last vestiges of ED.”
Me too.
i.e., I feel there is a false dichotomy set up sometimes where professionals with history of ED are always a bad thing (with the corollary that professionals without are always better or preferable.)
Personally, I would prefer professionals (psychiatrist, dietician, therapist) without an ED history, but there was another blog post on this a little while ago (where was this? I’m going to see if I can dig it up) and at least among those commenters, that opinion was vastly in the minority.
(sorry, I keep thinking of additional points)
…And that makes me wonder, what do professionals with an ED history seem to offer that those without that experience are not seen as able to provide? Are there unmet needs for clients that they perceive someone with shared experience would be better able to address, and what might these be?
Well, I think things that Katie and Rian “real” or deep understanding of what it is like to have an eating disorder? More empathy?
I’m personally not sold on this, but I can see how some would prefer a clinicians who has had those experiences, too.
Yeah, it is definitely a false dichotomy because ED history is just ONE of the many factors that determine clinician efficacy and all that stuff. Training, years of experience, gender, so many other things play a role in how patients click with clinicians.
I share your preference, but again, as I’ve said before, that’s based on a very small n number. Not scientific at all. Just my anecdotal experiences.
I have had a doctor who was VERY underweight…and that could have been just her genetics, but she was so underweight that I find it hard to believe. I suspect she had an ED, just from the way she spoke. It was incredibly triggering, I felt a huge amount of shame when talking to her about food, and I was constantly freaking out that she though I was fat. My ED got worse when she was involved because all I could think about was the shame of being bigger than her. Then there was this feeling like it was hypocritical of her to say I should gain weight when she was so clearly at a very unhealthy weight!
I have also had professionals who have disclosed about their own problems and it made me VERY uncomfortable…one time I just never went back to therapy again. I felt that I should somehow be saying supportive things to her, guilty for talking about my own problems, and scared that she would think my problems weren’t that bad compared to hers.
On the flip side I had a therapist who shared information about her own struggles (not ED related) in an appropriate way with me, and it helped massively. I felt more understood, and that I was talking to someone who was on my side. I think it’s dependant on the person and how appropriately they act within the therapeutic relationship.
Definitely someone who is visibly sick (or even if they are just very underweight, in the context of EDs, that’s a problem) should NOT be dealing with ED patients. I think your feelings are common. I went to a group facilitated by someone who had an ED and it was much worse than one that wasn’t (same group, facilitators changed). I remember lots of people talking about how she must be nearing a relapse (I didn’t think so, she didn’t look underweight, just small), but her constant talking about herself and her ED just took away from the group. Are we here for you or are you here for us, kind of thing.
I can see how sharing information can help, but I also don’t think it is always necessary. The best clinicians (ED-wise) that I’ve interacted with never shared any of their own personal struggles with anything (and didn’t have EDs), they were just open to what *I* had to say, they listened to *me* and tried to understand my thoughts, feelings, and emotions, as opposed to viewing them from their ED-tinted glasses.
I will do another post on countertransference, because that’s really the topic we are talking about. I found one interesting paper on it I’m planning to blog about.
Thanks for sharing!