Lately, I’ve been hearing a lot of noise in the social media sphere about whether or not those who have recovered from eating disorders should be treating eating disorders. Some have come out on the side of saying definitely not, listing reasons like the potential for bias, countertransference (the therapist making assumptions about clients’ emotions/experiences) or triggering. Others suggest that therapists who have “been there” can empathize with patients in a way that those who have not struggled with food cannot approximate.
Tetyana blogged about the lifetime prevalence of eating disorder professionals in recovery in 2013; she wrote about a 2002 study that revealed that around 33% of women and 2% of men treating eating disorders had a history of an eating disorder themselves. I have also written on the subject before (here); I focused on a 2013 study looking at experiences that recovered clinicians held in common.
Since writing that post, my opinions on the matter have not really changed, and likely won’t surprise you if you’ve read many of my posts and are familiar with my characteristic non-answer answers: I think it is impossible to categorically say that people who have had eating disorders should or should not be in the position of treating those with eating disorders. I think that blanket statements on either side are themselves extremely problematic. It assumes, also, that the person’s history of having or not having an eating disorder is the single most important thing about them, an assertion I find overly simplistic and, frankly, insulting.
So, if I’ve written about this before, why am I writing about it again? It’s a solid question, and the answer is not that I needed content. I recently stumbled upon an interesting recovery looking specifically at how recovered professionals conceptualized recovery, and couldn’t help but become fascinated as two of my interests converged into one article.
The Study
Bowlby, Anderson, Hall & Willingham (2015) conducted interviews with 13 American women who had experiences of eating disorders and went on to treat eating disorders. They were interested in better understanding how these women understood recovery, which, as we know, is a complex and poorly understood phenomenon.
The researchers asked clinicians:
- How they defined recovery
- Whether they saw differences between “in recovery” and “recovered”
- Where they thought they fell on this spectrum and for how long
- What was challenging about recovery
- What they learned about themselves in recovery
- How they currently relate to themselves, to their bodies, and to food/exercise
Participants were from 12 different states. All were of European-American backgrounds and all were women. Average age was 41.3 years (range 30-53). 5 held doctoral psychology degrees; 8 had masters degrees. Most worked in private practice (8 of 13).
With respect to their eating disorder history:
- Average length of illness was 11.2 (range 7-19)
- Average age of onset was 15.1 (range 10-21)
- Average length of recovery was 14.7 (range 6-24)
- 6 had a history of anorexia nervosa- restricting subtype (AN-R)
- 1 had a history of anorexia nervosa- binge/purge subtype (AN-BP)
- 3 had a history of bulimia nervosa (BN)
The authors used a phenomenological approach, trying to get to the root of how participants experienced recovery by coding their responses and reflecting on how the responses fit together to form a picture of recovery as experienced by these women.
Results
For these professionals, recovery was:
- Non-linear
- Comprised of both external and internal components
- Centered around learning about and valuing oneself
- Related to developing an understanding of the difference between the eating disorder and one’s identity
- Tied to finding meaning and purpose in life
- Contingent on developing healthy, meaningful relationships with others
By non-linear, participants described thinking about recovery as something that was continual throughout their lives, as opposed to having a strict beginning and end. Notably, however, this is not about having to continually strive to stay in recovery or something one thinks about constantly. As one participant noted:
“I don’t feel like I have to constantly work at being in recovery … I like to look at it as I am just constantly working to be a better person; constantly working to try to find balance in my life; constantly aware of myself every day.” (p. 5)
The comprehensiveness of recovery meant understanding recovery as more than simply gaining weight. Related to other recovery studies I’ve written about, this means that recovery does not spontaneously occur once one has normalized eating and reached a certain weight.
The authors note that participants saw recovery as tied to understanding and valuing the self; participants reported reaching a point of awareness of and grace toward themselves. As one participant put it:
“Recovery is definitely about moving beyond self hate […] Recovery is when you are not driven by the negative or the self-hate or the self-loathing. In recovery you are driven by the opposite, which is self-love.” (p. 6)
Again similarly to other recovery studies, participants de-identified with the eating disorder as they recovered and the eating disorder became less of an important part of who they considered themselves to be.
Participants also saw recovery as tied to finding meaning and purpose in life; of living a life not revolving around the eating disorder. Further, they described this life as having meaningful relationships in it.
What Does it Mean?
I think it is fascinating to look at how professionals with a history of an eating disorder look at recovery. I think this not because we should be making external judgment calls about whether they are fit to provide treatment for eating disorders, but because I think it is an interesting look at recovery from the eyes of people who have recovered, and yet work every day with those who aren’t yet there. Even more than that, this is a really interesting sample whose expertise is both lived experience and clinical competency.
Looking at the themes the authors found, it’s clear to me that the group was not only a group of women who had recovered, and thus had lived experience, but that they also understood eating disorders from a research and practice standpoint. I think this is something that gets overlooked in our discussions about both recovered therapists and recovery itself: rarely do people hold only one type of expertise.
People with eating disorders and in recovery may know a lot about eating disorders; if there’s one thing that frustrates me (ok, there are many things that frustrate me) it’s that there seems to be an assumption that people with eating disorders are engaging in eating disordered behaviour because they don’t know what it is doing to their bodies. “If they only knew better” people say, “they wouldn’t be doing this.” This couldn’t be farther from the truth, in my experience. This is the kind of ridiculousness that leads to people receiving only psychoeducational treatment for their eating disorder, with the expectation that increased knowledge will necessarily lead to behaviour change.
Often all this leads to is knowing all the ways that your behaviours, which you can’t stop, could be killing you. And systems that are left unchanged; people who feel they’ve done their bit to help you.
Regardless of whether I agree with the therapists’ perspectives on recovery – and I don’t categorically agree with all of them – I think it is important to look at studies like these to understand how these various sources of expertise can converge to create a picture of what recovery is. Therapists, regardless of whether they have recovered or never struggled with food in any way, are in the position of messaging to clients around what recovery is and how to get there, which is itself a powerful position that can strongly impact a client’s experience.
One of the most interesting conclusions the authors came to was that professionals in recovery tended to see recovery as very much achievable, but also as a process. I think this has important implications for messaging about recovery: I’ve heard in my research and advocacy experience that recovery as a “place” may feel overwhelming and unattainable. Perhaps if therapists themselves are on board with a perspective of process, clients will feel more comfortable with the journey.
A discussion about the fact that therapists saw relationships as a key aspect of recovery could likely be the basis of a completely separate post, so I will leave that part for now – however, I do think that this perspective may stem from the therapists’ occupation-based perspectives: therapists may be more inclined to focus on assisting clients in building solid systems of support and thus be invested in ensuring that their clients experience relationships in recovery.
Overall, this study provides interesting insight into a small sample of recovered therapists’ perspectives on recovery. Personally, I’d be eager to learn more about the experiences of recovered therapists from different social locations and practicing from different therapeutic orientations… research for another day?
As always, we could add complexity to the work by exploring and better understanding how therapeutic factors beyond having recovered factor into the clinical experience. I’ve said it once and I’ll say it again: it is unlikely that having recovered from an eating disorder is the only important thing about you. We need to talk more about other aspects of people’s lives that inform how they live, work, and interact.
Reference
Bowlby, C., Anderson, T., Hall, M., & Willingham, M. (2015). Recovered Professionals Exploring Eating Disorder Recovery: A Qualitative Investigation of Meaning Clinical Social Work Journal, 43 (1), 1-10 DOI: 10.1007/s10615-012-0423-0
I know this article is more descriptive, but I can’t help but think that personal characteristics that would make someone good at therapy in general have more predictive value for efficacy in treating eating disorders than personal history. Does personal history of the disorder even predict efficacy in treatment, or is it just that having the experience of struggling with an eating disorder will draw a therapist to practice in that specialty, rather than another? That being said, I did appreciate having the common experience of a group leader having also struggled with disordered eating. I felt deeply understood, which was comforting, but I think she possessed many other characteristics that enabled her to be a good therapist in general.
Yeah, I still personally would not want to have clinicians who have had ED histories. For me, the risk of them interpreting everything from their own personal lens, as opposed to actually listening to you when your experiences may contradict theirs, is too high.
Like “recovery is definitely about moving beyond self hate” is a great through and all, but I’ve never experienced self hate. These blanket statements, ugh, they anger me.
Yep, I agree that blanket statements like that are pretty irritating (very irritating actually) – that’s the predominant way recovery studies are written, a very typical perspective. I didn’t get into it too much because I recently wrote that other post about my dislike for that kind of framing, but what I do think is interesting about that framing in this case in particular is that I’m not at all surprised that therapists would frame it that way. Like I wrote, I think there’s something particular about the experience of having had an eating disorder, recovered in your own estimation and then working with others who aren’t there yet… almost a temptation to show that it is possible; to prove that recovery does happen, when some say it isn’t. I can’t help but wonder if those who recover and become therapists might be more prone to presenting recovery in a bit of a cheer-leader-y way? Obviously that’s based on speculation and observation, not hard data, but I do think there might be a tendency to upsell it. The ramifications of that could obviously be problematic if, as you’ve articulated, that’s an irritating way of presenting it. But then, I think therapists in general, irrespective of ED history, like to be pretty positive; obviously that’s an over generalization and obviously some think a lot about systemic factors, but I don’t know how common that is in the ED field in particular…
Anecdotally, it seems that those who recover/treat ED Px after their own ED recoveries are more likely to pursue careers in psychology vs. psychiatry. So, overall, they are likely dealing with a less severe patients. I wonder if that influences things, too.
I’d agree with that assertion, though I do wonder whether perhaps psychiatrists might be less likely to disclose their ED histories because of the nature of the field & how expertise is valued there? All speculation of course. But yeah, I think the severity of the patient the clinician/therapist is seeing could definitely impact their perspectives on & messaging around recovery.
Yes, different fields definitely have different standards and receive different training in various theoretical orientations (this may also vary by training program as well as by professional degree) which influence how much self-disclosure is considered appropriate or desirable, though there will also be considerable variability among individuals within a discipline (e.g., licensed psychologists) too. For example, in the US, a lot of therapy is now provided by Masters’-level clinicians (LCSWs, LPCs, LMFTs, LMHCs, etc.). I think social workers, whose field has a greater focus on social justice, contextual and strengths-based views of individuals and their problems, “lived experience”, feminist approaches to therapy, etc. tend to be more comfortable with self-disclosure. But the way in which social work has historically viewed psychopathology is very different than the traditionally deficits-based view of psychology and psychiatry, and I would imagine that this plays a role in how much concern there is with being stigmatized for one’s personal history.
Yes good point about disclosure. My guess would be that they’d be less likely to disclose, too.
I saw Julie O’Toole make this point on her Kartini Clinic blog (I looked and now can’t find the specific post, unfortunately), but I liked it: Why do we take issue with a ED clinician with an ED history, but we don’t automatically assume the incompetence of a depression clinician with a depression history, or an anxiety clinician with an anxiety history…? The latter are also extremely common, I would guess, but we never see the same kinds of objections. She suggested that judging a clinician based solely on their personal history amounts to discrimination.
This is of course thinking about this phenomenon on a MACRO level – individuals of course may have personal preferences for what they want or don’t want in a treatment provider which should be respected. Fwiw as a clinician in training I’ve been clear for a long time that I have no interest in treating or researching ED-related issues because I do feel, at least at present, that my experiences and beliefs might bias my scientific and clinical judgement (plus, I find other areas a lot more interesting, personally.)
It’s interesting that you say “For me, the risk of them interpreting everything from their own personal lens, as opposed to actually listening to you when your experiences may contradict theirs, is too high” because this is the EXACT PROBLEM I’ve had with SO many providers (including psychiatrists, dieticians, and physicians) — who don’t have an ED histories — based on their own preconceived notions of what EDs are, how they function, and what people with EDs need. Even now that I am pretty asymptomatic, I am still seen by providers through that ‘ED lens’ which is super frustrating. It’s a powerful deterrent to seeking services because it’s upsetting, exhausting and frustrating to think about the fact that I’m going to have to spend all this time and energy correcting their misconceptions before we can start getting anywhere remotely useful (and this is contingent upon their actually listening/caring about my perspective, not just blowing it off as another symptom of psychopathology, or defiance…when my experience contradicts theirs, I rarely have a positive/useful experience.)
I can’t comment on the anxiety and depression points because I simply personally don’t know; I have never sought out treatment for those because I don’t have an anxiety disorder and have never had depression. But I get your point. I think it is ridiculous to argue it is discrimination. My desire to not be treated by someone with ED history is my personal preference based on my personal experiences with therapists with and without ED histories. I definitely do not think there should be policies in place anywhere to prevent clinicians with ED histories from treating patients with EDs simply because of their history. I’d be very against that because I think that WOULD be discrimination. I get that a lot of people have the exact opposite preference to me, and the exact opposite experiences. In fact, I’d probably guess most people would RATHER work with someone who has personal history. I also get your experiences, and I think they are unfortunately very common.
I don’t buy O’Toole’s argument (as you reiterate it, I haven’t read what she actually wrote). EDs are fundamentally different from anxiety and depression because of their competitive nature, and I think that can really potentially complicate the patient-therapist dynamic in a way that I don’t see with anxiety and depression. I’d be curious to know your thoughts on that.
Oh, I didn’t mean that individual preferences were tantamount to discrimination! I think her comment was in response to a very, um, vocal individual who posts the same opinion over and over on many ED blogs about FBT, who was suggesting something at a systemic level (e.g., policy that ED therapists have required background checks, be required to answer numerous intrusive questions to verify that they are legit recovered, etc. From what I recall anyway. I wish I could find the post, it was pretty relevant to this discussion, argh.)
“EDs are fundamentally different from anxiety and depression because of their competitive nature, and I think that can really potentially complicate the patient-therapist dynamic in a way that I don’t see with anxiety and depression.”
Hm, I hadn’t thought about that. I guess I would say that there is potential for so many things to complicate the therapist/patient dynamic in terms of that sort of “countertransference” or whatever you want to call it, why single out EDs? I would say that if a therapist allows any competitive feelings that their client may trigger to impact their work with the client, then it becomes an ethical issue and they need to be alert to that possibility, recognize when it happens, and seek appropriate supervision/consultation in order to decide whether their reaction to their client is compromising their ability to do right by their client. Therapists aren’t blank slates, they’re affected by their clients in all sorts of ways. At least if you know you have potential for issues like competitiveness with clients based on your past history, you can take extra care to be vigilant and check in with yourself and your peers/colleagues/supervisors to make sure that you are handling such reactions appropriately when/if they arise – and be able to judge and get feedback from others on whether your reactions are getting in the way to the point where it would be in the client’s best interest to see someone else. If someone’s had decent training/is a decent person/has decent supervision, countertransference-type issues are really kind of a non-issue for the most part, and are really common. It’s sort of our default mode of operation as humans to try to understand others’ experiences through the lens of our own. Hopefully, part of any therapists’ training is learning to notice when that is occurring and the ways in which that can bias you. But I’m speaking as someone with clinical psychology training. I know other fields that offer counseling or psychotherapy may not be trained to be cognizant of and able to address such issues in the same way.
Also all this is assuming the therapist in question has attained a level of recovery/asymptomatic-ness/whatever you call it, such that the disorder is not compromising their ability to do their job. But there’s really nothing special about EDs in that – it’s a general part of the psychology ethical code that it’s unethical to practice when you are impaired by circumstances of your personal life, whether that be that you just lost your child to cancer and can’t stop crying even for a 50-minute session, that you have a substance abuse disorder, that you’re in a major depressive episode and can’t pay attention to what your client is saying because your mind keeps telling you to die, that you’re going through a divorce and keep spacing out while your client is talking to ruminate on how your ex husband is such a shithead and how much the lawyers cost….idk, I just don’t see EDs as a special case I guess.
I find it kind of odd that anyone would think to judge someone’s ability as a psychotherapist/psychologist based on whether they have had an ED. That is judging people who have had EDs as being somehow not fully human, irredeemably limited by their set views – especially where this judgement is being made by people who have not had EDs themselves. (I am still reeling from the newspaper storm we had recently in the UK about anorexia being narcissistic. I was shocked at the massive amount of hostility and negative preconceptions expressed about people with anorexia.) This is anecdotal, but I have often found ED sufferers to be among the most tolerant and empathetic of people.
I totally agree with your comments regarding therapists who list specific definitions of recovery, but I doubt that is unique to ED therapists with a history of an ED. That could be a problem with any human being, with any diagnostic history, working with any client group.
Agreed; I think it is quite odd how the eating disorder recovery becomes the central facet of one’s experience that people focus in on in this case. To be honest, I think people who’ve had eating disorders are just like everyone else… some might be tolerant & empathetic, yes, but some are also jerks 😉 Again, to me it’s not the most central thing about someone. Sure, it informs experiences & encounters with the world, but isn’t the only salient piece of someone’s identity. Perhaps having been through the amount of therapy people with EDs & other mental illnesses go through could definitely make people more introspective & self-aware. There’s something so paradoxical, I think, in the framing of eating disorder history as the most important driver of someone’s ability as a psychologist/therapist/practitioner of any kind and the attempt to destigmatize the experience of eating disorders.
Agreed. The fact that this survey was even carried out is suggestive of anti-ED stigma. Would the same issues be raised regarding therapists who had suffered depression/anxiety/OCD working with clients with these issues? I’m guessing no-one has any problems with that kind of scenario. Personally, I think it’s VITAL that former sufferers are included among ED professionals. Otherwise there can be a paternalistic power imbalance (sensible therapist vs immature, misguided sufferer), and a perpetuation of the prejudice – rife among health professionals – that people with EDs are somehow responsible for their condition.
Any well-trained therapist knows that every person they treat is unique. I’m betting the researchers just extracted partial comments that fit their objectives, then presented them as sweeping statements. And, in doing so, they made these ED therapists come across as set in their views.
“To be honest, I think people who’ve had eating disorders are just like everyone else… some might be tolerant & empathetic, yes, but some are also jerks”
#facts.
“There’s something so paradoxical, I think, in the framing of eating disorder history as the most important driver of someone’s ability as a psychologist/therapist/practitioner of any kind and the attempt to destigmatize the experience of eating disorders.”
I’ve noticed this too. I think this is one of the problems with the biomedical-explanation approach to trying to reduce stigma. A recent review found that framing mental disorders through that lens reduced stigma in some ways (e.g., people found individuals less blame-worthy), but it also increased stigma in other ways (e.g., their desire for distance, greater pessimism about prognosis, less likely to want a relationship with that person.) Part of this is science literacy and us researchers not always doing a great job of communicating findings – so when people hear things like “brain” and “genetic”, they think that the pathology is permanent, uncontrollable, and immutable. Our brains, genes, etc. can of course impact our psychology/behavior, but our behavior and psychological processes can also impact our brains and genes, for better or for worse! And that is a much less recognized fact. Anyway, rambling. I’ll try to dig up the citation.
This is the article I mentioned:
Haslam, N., & Kvaale, E. P. (2015). Biogenetic Explanations of Mental Disorder The Mixed-Blessings Model. Current Directions in Psychological Science, 24(5), 399-404. http://cdp.sagepub.com/content/24/5/399.short
“Abstract: Biogenetic explanations of mental disorder are increasingly prominent. However, they have decidedly mixed implications for how affected persons are perceived. We review evidence of these mixed blessings from three perspectives: how people with mental disorders are viewed by the public, by themselves, and by clinicians. Although biogenetic explanations may soften public stigma by diminishing blame, they increase it by inducing pessimism, avoidance, and the belief that affected people are dangerous and unpredictable. These explanations may also induce pessimism and helplessness among affected people and reduce the empathy their treating clinicians feel for them. We interpret these findings in light of social psychology research on essentialist and mechanistic thinking.”
It is my personal preference that is based on my experience. It has nothing to do with judging them as being somehow not human (?? what?). I would just rather minimize the chances of ED-related countertransference. The other issue I have is that I think a lot of people who have ED histories and go into treating EDs aren’t really recovered to the extent I’d want them to be if I were to be treated by them.
I have had very good experiences with clinicians without ED histories, and many very irritating and annoying experiences with therapists who have had ED histories. It is a limited sample size, but it is enough to bias my preferences regarding therapists.
“I have often found ED sufferers to be among the most tolerant and empathetic of people.” I haven’t found that, personally.
I wonder, when we talk about our experiences with clinicians with/without ED histories…if it’s not the ED history that’s the factor, but maybe the disclosure? If they don’t tell us, we would never know they had a history. So maybe the disclosure is just a symptom of their being a shitty therapist, ha. There are a LOT of people who self-disclose for the wrong reasons (“every time you’re tempted to disclose some personal info, ask yourself – what’s my motivation? Am I doing this because it helps the person sitting in front of me? Or because it helps me?”)
Anyway, I have zero problem with individuals having preferences about whether they want a clinician with/without an ED history. Just not a fan of the line of thinking around whether people with ED histories should be “allowed” to practice, as if there is something special about an ED diagnosis that renders that person incompetent and inherently irrational/biased/untrustworthy for all eternity. (I know you’re not saying that, T. But on a macro level there is a degree of stigma around the ED diagnosis – more than depression/anxiety, but less than schizophrenia/BPD – that I find extremely bothersome and kind of scary.)
Dieticians/nutritionists with EDs/disordered tendencies on the other hand…don’t get me started!
My post was responding to the beginning of Andrea’s article (“a lot of noise in the social media sphere about whether or not those who have recovered from eating disorders should be treating eating disorders”.), It wasn’t aimed at your comment, Tetyana.
Judgement (regarding therapists with ED histories working with ED patients) is radically different if it comes from people who have never had EDs or if it expresses the personal preferences/experiences of people with EDs looking for treatment. It’s only the first type of judgement that is worrying.
“Judgement (regarding therapists with ED histories working with ED patients) is radically different if it comes from people who have never had EDs or if it expresses the personal preferences/experiences of people with EDs looking for treatment. It’s only the first type of judgement that is worrying.”
Thanks Shiran, you summed up what I was trying to say very succinctly! (Note to self: take melatonin AFTER commenting on blogs, not before.)
My current therapist is in recovery and very open about it and I must say, it has been the KEY GAME CHANGER in my own recovery trajectory. I should say that she is 100% “in recovery” but after working with many many therapists I think having someone who has been through it is immensely helpful in a myriad of ways