A big topic at ICED, and one that seems to continually resurface, is treatment professionals in recovery. One the one hand, many see healthcare professionals with a history of eating disorders as possessing a kind of empathy that may be inaccessible to those who have not “been there.” On the other, some argue that this history complicates the patient-professional relationship in potentially detrimental ways.
You’ll find proponents of both sides of this debate from both professional and patient communities, and there are compelling arguments to be made on both sides of the coin. As an eating disorder researcher with a history of eating disorders, I don’t think you will be surprised that I lean toward the “it’s totally fine” side of the debate.
One thing that stood out to me about the larger discussion on this topic at the conference, however, was how we need to be careful about not stigmatizing those who either do or do not have a history of eating disorders. For some, becoming a professional treating eating disorders might be a great way of making sense of an incredibly difficult experience. For others, this might be counter-productive and maintain a problematic fixation.
It is a huge over-simplification to say that either individuals with or those without eating disorder experiences make better clinicians- basically what that does is ignores all the other parts of an individual’s life that make up who they are, and I should like to think we’re past that kind of reductionism. Generally, there needs to be an acknowledgement that an eating disorder is one experience among many, and that everyone makes meaning of this experience differently. Easier said than done, of course, and there seem to be reactions in the extreme when anyone brings up this topic.
Perhaps unsurprisingly, researchers have also been investigating in this area. Warren, Schafer, Crowley & Olivardia (2013) conducted a qualitative study looking at the common experiences of treatment providers with a personal history of eating disorders.
How Many Treatment Providers Have a History of EDs?
The stats on clinicians with a ED history are somewhat murky. A 2002 survey of Academy for Eating Disorders members revealed that approximately 1/3 of members (who took the survey) had a history of eating disorders (Barbarich, 2002; Tetyana blogged about this study here); anecdotally, conversations about this topic have indicated that perhaps up to half have experienced eating disorders.
It is important to note that these studies estimating prevalence have their own limitations. If there is indeed a stigma around being a professional with a history of an ED, it is unlikely that one would take a survey disclosing this history. Conversely, individuals with an ED history who are interested in tackling this stigma might be more likely to take such a survey in order to normalize the experience.
Also, I am not sure whether these figures capture subclinical disordered eating; one study by Bloomgarden, Gerstein & Moss (2003) suggested that up to 24% of clinicians in an eating disorder treatment facility had experienced clinical eating disorders and 7% had experienced “eating problems.”
So while it might be tempting to answer the question of “how many treatment providers have a history of EDs?” with “a lot,” the best we can really say with certainty, at this point, is “likely quite a few, but we need to do more research” (isn’t that always the answer to everything?).
THE STUDY
Warren and colleagues drew their sample from an extensive study investigating burnout among clinicians treating eating disorders; of 298 clinicians included in the larger study, 47% (139) were included in this study after disclosing their personal histories of eating disorders.
The authors designed an open-ended questionnaire centered around practitioners’ experiences with eating disorders, how they felt this impacted clinical practice and what they might recommend to other practitioners.
The researchers present their results in a very quantitative way, despite the qualitative nature of the data; I find this interesting, but then I find methodology, epistemology, and ontology interesting so I might not be your average reader. In any case, this allows for reporting percentages of respondents who shared experiences.
135 participants were women, 5 were men. Mean age was 44 (range 25-65); most participants were White/European American, from the US, had Masters degrees or PhDs, were married, and were in private practice with patients with eating disorders comprising the bulk of their caseload.
In terms of eating pathology:
- All had a history of “an eating disorder or strong eating disorder symptoms”
- 8% (11 participants) currently had an eating disorder
- 31% had not been diagnosed but had experienced symptoms of EDs
- 23% had been diagnosed with AN
- 19% had multiple diagnoses over the course of their lives
- 13% had been diagnosed with BN
- 8% had been diagnosed with EDNOS
- 7% had been diagnosed with BED
Practitioners used a range of therapeutic approaches, including CBT, psychodynamic/psychoanalytic, integrative/eclectic, humanistic, and medication approaches. Clinicians had been practicing for a mean of 12.5 years (range 9 months-37 years).
RESULTS
Most participants (89%) thought that having experienced eating pathology had positively impacted their practice. These positive impacts included:
- Facilitating a non-judgmental orientation
- Understanding clients’ emotional processes
- Providing a “unique perspective” perhaps inaccessible to other clinicians
- Keeping positive about the possibility of recovery
- Increasing passion for helping others
- Helping with patient-therapist alliance
Some (9%) saw both positive and negative sides, and 2 participants perceived their experiences to have only negatively impacted practice. Negative experiences included:
- Feeling personally triggered
- Over-identifying with patients (e.g. leading to bias)
A quote from a participant illustrates the kind of “positive-but-negative” bind of having personal ED experiences:
I understand the underlying emotional/psychological etiology and maintenance factors firsthand, which at best increases empathy and at worst may lead to biases.
When asked to provide advice to new clinicians with an ED history, participants encouraged working with a therapist on personal recovery prior to engaging with clients for the well-being of the clinician and the client alike. Among other recommendations, practitioners urged:
- Self-awareness to avoid projecting personal experiences onto clients
- Being conscious of triggers and staying accountable in recovery
- Being aware of personal limitations
- Engaging in self-care
- Seeking social support
- Maintaining boundaries
- Talking with other health care providers with similar experiences
Self-disclosure seems to be another “hot topic” in this area, and participants held mixed views on the appropriateness and relevance of disclosing ED history to patients. Interestingly, only 12% of participants specifically touched on the issue. So, within the broader sample:
- 8% urged careful consideration in self-disclosure
- 4% suggested that self-disclosure should always be avoided
- 1% thought self-disclosure was uniformly helpful
Participants were also able to share general reflections on their experiences; in so doing, practitioners:
- Encouraged a focus on small successes in providing therapy
- Provided advice about making the work easier, including maintaining boundaries, seeking supervision, and managing case load
- Commented on difficult issues including feeling unsupported at work
- Urged other practitioners to avoid taking on unsuccessful outcomes, highlighting the multiple factors (beyond just therapy) that can impact patient outcomes
IMPLICATIONS
It is telling that most participants acknowledged the role that personal ED history can play in practice. Obviously, these professionals are well aware that there are (at least) two sides to a therapeutic relationship, and that their experiences including (but, I would argue, not limited to) their ED history play a role in therapeutic alliance. As the authors note, their findings map onto other similar studies looking at treatment providers’ personal ED experiences.
One feature of this study that I really appreciated was that the researchers asked what advice participants would provide to newer practitioners. Given that one such suggestion was that individuals should seek out others with shared experiences, opening up this discussion seems like a good idea.
As the authors note, clinicians’ personal experiences are overtly invited in some mental health fields, for example substance abuse. This happens in some spheres in the ED treatment field, and some treatment programs specifically seek to hire counselors in recovery (Costin & Johnson, 2002). Somehow, though, clinicians-in-recovery remains somewhat controversial in the ED field. Perhaps this is because recovery is an ill-defined construct, making it difficult for providers to “objectively” demonstrate recovery before engaging with clients, which participants indicated was key.
Going back to the idea of stigma around being a professional in recovery, I think it is very important to avoid saying 2 things:
- That EDs should be treated only by individuals who have “been there”
- That EDs should never be treated by individuals who have “been there”
Personally, I strongly believe that the experience of having an eating disorder is one element of a therapist/researcher’s collective life experiences that might colour one’s approach to treating clients (or, in my case, doing research). We all have biases based in any number of life experiences; having experienced an eating disorder is just one of these. Being up front about these potential influencing factors helps us (and other who judge our work either implicitly or overtly) to be transparent about where we are coming from and to recognize our strengths and limits.
Where it gets a bit tricky, looking specifically at therapists in recovery, is around self-disclosure to clients in particular. As the authors note, we still know relatively little about how clinician self-disclosure impacts participants; moving forward, it will be important to investigate this further. Ultimately, the goal is to help clients in their recovery; to assume that there is one best way to do this is naïve.
As I was writing this post, I started wondering what all the fuss is about, to a certain extent. Why are we not talking about how a variety of experiences might impact clinicians’ ability to treat patients? Focusing solely on the ED experience makes it seem like having had an ED is the biggest and most important thing that determines what kind of clinician someone will be, which seems a little counterproductive and stigmatizing.
Anyway, I know there are lots of varied opinions on the topic, and I’m open to hearing them. What do you think, readers?
References
Warren, C.S., Schafer, K.J., Crowley, M.E., & Olivardia, R. (2013). Treatment providers with a personal history of eating pathology: a qualitative examination of common experiences. Eating disorders, 21 (4), 295-309 PMID: 23767671
I have been scouring the internet for ages looking for articles/information relating to this subject! I worked for a short time as a professional in an eating disorders ward, and ultimately, I relapsed terribly. My recovery was more fragile that I thought, and despite having assured myself that it would be fine, it most definitely wasn’t. I think it can be incredibly useful and helpful to have a degree of empathy that it is difficult to emulate without first hand experience of an ED, but I would say be mindful of your own recovery. Be honest with yourself about whether you are working in that environment because you want to use your experience in a positive way, or if you may have been seduced by the world of eating disorders for the wrong reasons.
Thanks for commenting, Sasha! I’m sorry to hear about the relapse while you were working as a professional in the field. I think you make a great point about being honest with yourself- I think in general there should be an emphasis on health practitioners taking care of their own health, regardless of what their history is (be it ED or otherwise).
Andrea, I am so impressed with how thorough your posts are. I’ve seen your blog before but am making more of a commitment to follow blogs in the field, so I’ll definitely be coming back more often.
As a recovered (I say that under my breath because of all the controversy it carries) ED clinician, I have definitely struggled with how my past does and does not have a role in my work with clients. Most of the time, I find it very helpful to be able to know what it feels like to struggle with those exact issues — but I have definitely met ED treatment professionals (like our awesome RD) who do not have personal recovery and SO get it. (Though of course, clinicians who have no personal experience AND not been trained to specifically work with ED and do anyway can say/do cringe-worthy things.)
But as I alluded to, I have had issues with self-disclosure and my stance of “recovered,” especially because I work in a facility that has historically been primary substance abuse treatment (though our unit offers primary ED as well.) As you mention, self-disclosure in that space is quite the norm, if only identifying oneself as a recovering addict and not giving much more detail. Do that with ED — “I’m recovered from an eating disorder” — and you will stir the shit with substance abuse professionals or treatment-savvy clients with addiction issues. It got to the point where my team agreed we just would not check in with that information anymore. I will still self-disclose when it’s clinically useful for me to identify with a client’s experience, but I try not to have to use the language of “recovered/recovering” because it’s not worth the political fallout in my particular job. Way more than my 2 cents and somewhat of a tangent, but glad I had a place to share!
Valerie
Thanks for your kind comment, Valerie. I’m glad you enjoyed the post and hope that you’ll keep coming back to the blog! Thanks, too, for your insights as an ED clinician with a history of disordered eating. It seems to me that you’ve hit the nail on the head when you mention the need for training working specifically with individuals with EDs- I would say for both those who have and those who haven’t experienced EDs, this is absolutely essential- we hear way too many horror stories about cringe-worthy comments and actions from clinicians who don’t “get it.” Maybe the training would look slightly different for those who have experienced EDs; as you say, issues of self-disclosure can be extremely tricky; it might be nice to have more support around discussing issues of self-disclosure and how/when to do it/not to do it. I think sometimes it can be easy for people to discount the job politics you discuss, and think about the issues with self-disclosure only between patient and client, when there are really so many dynamics going on “behind the scenes,” as well, which can have real impact!
Thanks for this article! I am a nurse in the ICU, but when I was in school, I always thought about working in nursing in psych/EDs. At one of the treatment facilities I went to (where I had both negative and positive experiences but really stabilized me at a time when I was at my rock bottom), I stayed afterwards in the transitional living home, which was run by a woman who had been a patient fifteen years before and was now a psych professional living in recovery and very open about it, and I got so much hope out of hearing her story.
I thought I wanted to help people “like me,” but I think at that point, so much of my identity was wrapped up in my eating disorder that I thought it was really “who I was” and I think that the idea of recovery was so scary that it sounded more manageable if I could kind of stay connected to the eating disorder by talking about eating disorders all day. I’ve begun to kind of unravel myself from the eating disorder, which I say not meaning I’ve “found recovery” because I still binge and purge, I still, by all accounts, have an eating disorder, and I still sometimes feel hopeless about it. But I also know that I am a lot of other things besides a person with bulimia, and I am never just “a bulimic.” I’ve kind of swung completely in the opposite direction, and when we had to talk about eating disorders in class, I hated every minute of it. I knew as I listened to people discuss what was a deeply personal topic for me that I could not use my “clinical” brain in this area in a way that would be fair for patients, and that, actually, when I went to do my clinicals in a psych hospital with patients who were struggling with suicidal depression and anxiety and sat talking with teenage girls who reminded me so much of my teenage self it was silly, I felt like I was being punched in the stomach and like I was a big fraud for pretending to have the answers when I was going to go home and throw up.
So I’ve found that in order to protect my recovery, I already think about the eating disorder so much that I can’t make it my job to think about it. I admire people who do and who are able to do so in a way that is helpful for others, like the case manager at the home. But I just couldn’t, and I think if I had tried, I would’ve done more harm than good, both for myself and for my patients.
Thanks for the insightful comment, Katie- it is great to hear the perspectives of individuals who have lived experience in this area. I really do think we need to be talking more about the positive and negative elements of the experiences of being a healthcare practitioner with a history of an eating disorder in a way that goes beyond simply saying “never do it!” or “its always a good idea!” As your comment so clearly demonstrates, it is so much more complicated than that. I think its great that you recognized what works (and what didn’t work) for you, and how working in the field would have impacted you and your patients. I really appreciate, too, how you did find that your case manager had a different experience and that you found her helpful and effective.
I agree completely Katie, your experience sounds very similar to mine. I found I wanted to work in eating disorders to somehow maintain that connection… and realising I couldn’t both do that and stay in recovery was a really difficult, and went against everything I felt was “right”. I am training as an occupational therapist and have made a conscious decision not to practice in the area of eating disorders, and have spoken to my tutors to ensure I am not put on placement in the area. Its a tough choice but a necessary one and I take my hat off to you for realising it wasn’t going to work for you. I agree too that for some people, it can be nothing but beneficial to patients and have no affect upon the professional’s health.
For me, the question of disclosure links back to a lot of the issues discussed in your post about patients’ interpretations of therapists’ bodies. I had a therapist who I felt had an almost intuitive understanding of how I felt and what I wanted to say. Only after I finished seeing her did I find out that she had recovered from an eating disorder, but I felt very relieved that I didn’t know that at the time. She was slim – not unhealthily so, but enough that it might have made me either question the validity of ‘recovery’ or judge / compare my own.
There would also be the question with ED disclosure of type / sub-type and the comparisons and shame that might come in to play, in for example, a clinician with a history of AN-R and a patient with BN, or vice-versa.
I once attended a lecture by Susie Orbach who said that clients with EDs make a massive demand of the therapist’s body – there were lots of nodding heads in the room. I’d completely agree that there are no general rules about recovered Vs ‘naive’ professionals, but the type of treatment practised might well affect clinician bias or ability to maintain boundaries. The study didn’t separate them out, but recovered clinicians practising psychoanalytic therapy might need more support that those practising CBT.
I agree that there is a link to be drawn between disclosure and patients reading therapists’ body size; in some cases, as you note, the disclosure might complicate clients’/patients’ reactions to their readings of their therapists bodies (including by perhaps confirming or disconfirming their prior assumptions about their body size & ED/recovery history). You make a good point, too, about the nature of the diagnosis disclosed… I’ve been reading about the hierarchization of diagnoses lately & differences in stigma and shame and I definitely think these could play into feelings of one’s own disorder in relation to a clinician. All of these things make disclosure such a grey area- something to continue thinking about and to negotiate in light of patient-therapist relationships and boundaries.