The thing about critiquing systemic issues like lacking training environments for medical professionals (and others) is that we have to be cautious to not place undue blame on those who are stuck immobilized between the desire to a) train or b) get training in eating disorders. If the solution to the egregious lack of training was simple, I feel sure that someone would have done it already! What I am gesturing at, here, is that the reasons behind lacking training opportunities are deeply rooted in socio-political, historical, and economic trends and policies. Those providing training and those seeking training do not exist in some glorious black hole devoid of austerity (frugalness, restrainedness) and neoliberalism.
In this post I’ll focus on a few studies that help to illuminate why these gaps in training might exist, including dominant sentiments (in the general public, in government, in training environments themselves) toward eating disorders. I’ll also highlight some promising directions in rectifying the situation. I’ll start with an exploration of the potential ramifications of this lack: burnout amongst those who do decide to treat eating disorders.
Burnout Amongst Treatment Professionals
A recent article by Warren and colleagues (2013) indicates that people treating eating disorders often experience emotional exhaustion, one of the key components of burnout. Warren et al. wanted to find out which clinicians, under which circumstances, might suffer burnout, how this compares to other mental health fields, and whether there is something about treating eating disorders in particular that might lead to burnout amongst those treating people with eating disorders.
I think it is important to note at the outset that we need to be very cautious of interpreting this study and similar others as indicating that people with eating disorders are “challenging to work with.” Eating disorders are incredibly complex and multi-dimensional disorders; it is less about individuals with eating disorders being challenging to treat and more about thinking about the environmental and disorder-related factors that might increase the complexity of managing eating disorders.
I note this because I fear that the idea that people with eating disorders are “challenging” or “trying” to work with, or “treatment resistant” makes for a dangerous scenario that reinforces the lack of training I’ve been writing about in this series, thus far. It is important to look beyond individualizing blame and expand our point of view on what the real “challenge” is.
Getting back to the study, Warren et al. gathered a group of 296 participants from a mixed group of healthcare providers, including psychotherapists, psychologists, and psychiatrists. All of the clinicians were currently working with patients with eating disorders (290) or had in the past (6).
Participants varied widely terms of experience (from 8 months to 37 years, with an average of 13 years) and percentage of eating disorder cases on their caseload (on average, 65% of case load in eating disorders).
Looking at specifics:
- 23% had experienced a client’s death during their experiences treating eating disorders
- 47% reported a history of an eating disorder (mainly AN, but also BN, EDNOS, and multiple diagnoses)
- 4% reported currently having an eating disorder
- 16% reported suffering (at the time of the study) with mood/anxiety disorders
- 54% reported having had a mood/anxiety disorder in their past
- Often, those who reported currently or previously suffering from an eating disorder also currently or previously suffered from an mood/anxiety disorder
Perhaps encouragingly, the authors note that their sample’s scores on the Maslach Burnout Inventory indicated that they were less burnt out than other mental health professionals (as report in the literature the reviewed) in terms of cynicism and personal accomplishment. Participants had similar levels of emotional exhaustion to other providers.
There were varied amounts of burnout within the group of eating disorder professionals they surveyed. Among the interesting findings the authors report, it is notable that those who scored higher on emotional exhaustion and/or cynicism:
- Were younger than 35
- Had a higher BMI
- Were single
- Had no children
- Had a history of mood/anxiety disorders
- Had a doctoral degree
- Had less than 5 years of experience treating eating disorders
- Worked in hospitals or a combination of settings
- Worked more than 35 hours a week
Interestingly, there were a number of things associated with feeling more personally accomplished in relation to the job, including:
- Being male
- Having a personal history of an eating disorder
- Having 15 years or more experience treating eating disorders
- Working in private practice
- Had more than 40% of their caseload in eating disorders
I think the most interesting result here is that those who worked in hospital settings or floated in between multiple spaces felt most burnt out and less personally satisfied with their work. To me, that speaks to aspects of the work environment that link back to discussions of negative feelings toward eating disorders in medical settings, including training environments.
Working in private practice, you’re likely surrounded by like-minded individuals who share values and treatment philosophies with you. In larger settings, there is a lot more going on that could lead to value clashes and priority differences. I can imagine that particularly today, in a society wherein anti-obesity is the norming trend, it could be challenging to advocate for the necessity of your work in treating eating disorders when the dominant (false) sentiment is that eating disorders are somehow “less important.”
Of course, this is just me making some connections to the broader world; the authors restrain their conclusions to indicating that overall, eating disorder treatment professionals are less burnt out than those in other mental health fields, but more emotionally exhausted. They explain that this could be tied to the participants’ sense of commitment to the work, or to the fact that those who had burnt out completely had left the field (i.e., had not participated).
So, what am I trying to get at when I say “the negative feelings toward eating disorders in medical settings including training environments”? Turning to a few more studies, I’ll briefly outline what I mean.
Stigma Toward Eating Disorders in Training Environments
What might help to explain the dearth of training opportunities for those interested in eating disorders is that, as I’ve alluded to, people don’t always have the most optimistic or generous outlook toward those with eating disorders. Amy Bannatyne pointed me toward a recent article in which she and her co-author, Peta Stapleton (2015) created an invention aiming to minimize stigma about eating disorders amongst medical students. Before getting into that study, I’ll briefly touch on some others that lay the groundwork for the need for such an intervention.
As I noted in part 2, some medical residents reported negative sentiments toward eating disorders in their training environments. Jones, Saeidi & Morgan (2013) were also interested in this phenomenon: they sought out to determine how “mental health literate” psychiatrists were in eating disorders.
Jones et al. found that amongst 126 (primarily non eating-disorder specific) psychiatrists recruited from the UK:
- 9% thought that they could manage eating disorders in their present work
- 4% were satisfied with the amount and quality of training they’d received in eating disorders
- 5% felt that they could diagnose eating disorders
There were some negative sentiments and misconceptions about eating disorders amongst these clinicians, including that:
- Some psychiatrists thought that eating disorders as linked to weakness, manipulative character, or a personal failing (7.8% for AN, 4.3% for BN); for BN, this view was more prevalent amongst junior psychiatrists
- Some thought that eating disorders are “essentially untreatable” (1.7% AN, 0.9% BN)
- 2% of psychiatrists thought that the cut off BMI for AN is lower than it actually is
- 7% of psychiatrists thought that the NICE recommends SSRIs for AN
While the percentage of psychiatrists with extremely problematic views on eating disorders (i.e., that they are somehow indicative of a character flaw) is relatively low, I would argue that any clinician holding this attitude is problematic. I was pleased to see, however, that psychiatrists held this view to a much lesser extent than other doctors; the authors report on other literature, for example highlighting a study indicating that 31% of OB/GYNs hold this pejorative stance (Morgan, 1999).
As Fleming & Szmulker (1992) report, following a study of 352 medical staff at an Australian hospital, a mixed group of medical professionals can hold highly problematic ideas about what causes eating disorders. In their sample, many professionals perceived those with eating disorders to be more responsible for their illness than those with other mental illnesses; for example, the nurses in the sample thought people with anorexia were, on average, 67.9% responsible for their disorder while they saw people with schizophrenia as 16.2% responsible.
As much as I’d like to think that the tides have turned in terms of negative attitudes toward those with eating disorders amongst medical professionals, a literature review by Thompson-Brenner, Satir, Franko & Herzog (2012) indicates that some stigma remains, particularly amongst early career medical professionals. However, their review also demonstrates that there may be some improvements as clinicians gain experience. Perhaps most interestingly, one of the studies they reviewed (Reid, Williams & Burr, 2010) revealed that lacking resources around providing treatment were of a greater concern for clinicians than “challenging” patients.
Further, as many of the articles I’ve reviewed for this series continue to emphasize, clinicians often felt ill-prepared to handle the complexity of eating disorders. Thompson-Brenner et al. suggest that knowing where the areas of resistance, stigma, and misunderstanding are can help us to move forward. Not only does training need to exist, but it needs to be complex, multi-dimensional, and focused on reducing misinformation and stigma. As the authors write:
“The number of available and trained providers will need to increase to treat higher numbers of patients with eating disorders. Understanding the reluctance of providers to treat eating disorders and developing educational, training, and supervision opportunities to counter these reactions are critical tasks” (Thompson-Brenner et al., 2012, p. 77)
And promising directions do exist. For example, Ballantyne & Stapleton (2015) designed an educational program aiming to decrease the kind of stigma about the personal responsibility for eating disorders described above. They delivered the intervention in the form of a small 3-condition study (where participants were assigned to an education intervention with an emphasis on biogenetics, an education intervention with a multi-dimensional focus, or a control group). Participants in either of the education conditions were less likely to:
- Report stigma toward those with eating disorders
- Blame people with eating disorders for their illnesses (stronger in the biogenetic group)
- Think that people with eating disorders are selfish or vein
- Think that people with eating disorders were responsible for their illness
Though this study reveals promising results, it was on a small scale. It is somewhat unclear how willing medical schools might be to implement such interventions, particularly given that, as we’ve seen, there has not been much movement toward increasing training over the past years.
What Do Stigma and Burnout Have to Do With It?
So, maybe you’re wondering how I possibly plan on bringing all of this together. Perhaps you’re feeling like I just dumped a bunch of doom and gloom on you, and wondering where we go from here. Well (hopefully obviously), that is not my intention. What I want to draw our collective attention toward, here, is how:
- Lacking training is a serious concern, both in the medical field in general, where it may lead to clinician inability to recognize eating disorders at an early stage and intervene accordingly, particularly amongst those who don’t fit the stereotypical image of “a person with an eating disorder,” and in the psychiatry field in particular, despite that being a place we might expect to be a bastion of understanding.
- When training does exist, it is not always satisfying for healthcare professionals, who may emerge feeling ill prepared to take on the challenge of treating such complex disorders.
- There are deeply entrenched stigmas around mental illness in and beyond the medical field. As experience increases and training improves, so too does stigma decrease.
- Faced with this kind of lacking training and relative lack of support for the training in and treatment of eating disorders, professionals may burn out of the field, leaving in place a paradox where there are few “experts” to train the next generation of experts.
That said, the situation is far from hopeless. Hopefully, by having these kinds of studies out there, and by sharing them widely, especially with those in positions of power to actually make change, we can start to shift the training environment. After all, what is the point of all of this quality research if not to bring it into practice?
I had intended on providing more of an emphasis on the neoliberal-medical-complex that makes all of this challenging to surmount, but this post has rambled long enough- feel free to ask in the comments if you’re interested! Elsewise, it’ll be another post for another day.
Bannatyne, A., & Stapleton, P. (2015). Educating medical students about anorexia nervosa: a potential method for reducing the volitional stigma associated with the disorder. Eating Disorders, 23 (2), 115-33 PMID: 25401522
Fleming, J., & Szmukler, G.I. (1992). Attitudes of medical professionals towards patients with eating disorders. The Australian and New Zealand Journal of Psychiatry, 26 (3), 436-43 PMID: 1417629
Jones, W.R., Saeidi, S., & Morgan, J.F. (2013). Knowledge and attitudes of psychiatrists towards eating disorders. European Eating Disorders Review, 21 (1), 84-8 PMID: 23350077
Thompson-Brenner, H., Satir, D.A., Franko, D.L., & Herzog, D.B. (2012). Clinician reactions to patients with eating disorders: a review of the literature. Psychiatric Services (Washington, D.C.), 63 (1), 73-8 PMID: 22227763
Warren, C.S., Schafer, K.J., Crowley, M.E., & Olivardia, R. (2013). Demographic and work-related correlates of job burnout in professional eating disorder treatment providers. Psychotherapy (Chicago, Ill.), 50 (4), 553-64 PMID: 23795947