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?).
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).
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
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?
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