To Tell or Not to Tell: Therapists With a Personal History of an Eating Disorder
By Carolyn Costin M.A., M.E.d., LMFT, FAED, CEDS and Alli Spotts-De Lazzer M.A., LMFT, LPCC, CEDS
This is the first of a 2 Part series on Recovered Therapists and the Treatment of Eating Disorders.
Whether or not a therapist with a personal history of an eating disorder should treat patients with eating disorders and disclose that history has long been a subject of debate. The discussion continues—without resolve—between proponents in favor and those who oppose such self-disclosure. It is important to note at the outset of this article that both authors are therapists who have recovered from an eating disorder and support appropriate self-disclosure in the therapeutic relationship. We believe that being recovered from an eating disorder can be a significant asset when working with eating disorder patients.
Research indicates that a significant number of eating disorder treatment professionals have personally experienced an eating disorder. Early reports suggested about one out of three or four (Barbarich, 2002; Bloomgarden, Gerstein & Moss 2003; Johnston, Smethurst, & Gowers, 2005; Shisslak, Gray, & Crago, 1989; Warren, Crowley, Olivardia, & Schoen, 2008). More recent reports indicate perhaps even higher percentages. De Vos and colleagues (2015) noted that eating disorder clinicians with personal eating disorder histories ranged from 24% to 47%. The 2013 Academy for Eating Disorders online survey (unpublished) spearheaded by Dooley-Hash, de Vos, and the Professionals and Recovery Special Interest Group, revealed that out of 482 respondents from the Academy for Eating Disorders, International Association of Eating Disorders Professionals, Binge Eating Disorder Association, and Sports, Cardiovascular, and Wellness Nutrition, 262 (55%) reported a personal history of an eating disorder. Of the 262 professionals with personal histories of eating disorders, 182 (51%) reported working directly with eating disorder patients. Since many eating disorder therapists have had eating disorder histories, and according to Bloomgarden and colleagues (2003), 67% of therapists surveyed used self-disclosure in their treatment approach and “all recovered clinicians used it in their therapy in some way” (p. 165), it seems important to explore this topic further and assist clinicians in this area.
Over the years, some have suggested that clinicians with eating disorder histories should not disclose this to clients, while others have suggested they should not even work with eating disorder clients. As reported by Johnston and colleagues (2005), Clothier, MacDonald, and Shaw (1994) suggested that individuals with an eating disorder history be banned from the nursing profession, while Bullock (1997) recommended they be banned from all healthcare professions in the United Kingdom. Many have expressed concerns, listed potential disadvantages, and devised parameters to follow if a clinician with a personal history of an eating disorder wants to work in the field. In 2003, the issue was debated by the European Council on Eating Disorders, however, an agreement on whether clinicians with a history of an eating disorder are at a disadvantage when working with eating disorder clients could not be reached. What are the factors keeping us from some kind of consensus on this issue?
This article briefly looks at the history and literature on the topic of clinicians with an eating disorder past, explores values and pitfalls of these clinicians disclosing or not disclosing their history, the need to clarify terms in the field, and defining “recovered.”
The Value of Recovered Clinicians
Carolyn: “I saw my first eating disorder client in 1979 and told her I was recovered from an eating disorder. I also said, ‘If I recovered, so can you.’ She recovered and I’ve been saying the same thing to all clients ever since. Sharing my eating disorder history and serving as a role model and guide for others has been a huge aspect of my success as a therapist in the eating disorder field.”
Alli: “As a developing eating disorders therapist, I sought a place to train where I didn’t have to hide that I once had an eating disorder and could allow that personal experience to be a part of the work—not a dominant part, as the clinical aspects need to be, but not a hidden part, either. So my first day as a trainee therapist was with Carolyn Costin at Monte Nido. Almost 10-years later, I can wholeheartedly say that both having learned appropriate parameters about, and having had permission to disclose my status of being recovered has helped many of my clients to believe that freedom from an eating disorder is possible—AKA ‘hope.’”
Carolyn: “I learned early on that a recovered clinician has the unique value of having lived with a brain that was once hijacked by an eating disorder and then having successfully gotten their real brain back. Having been through it, these clinicians can explain to clients, as well as to other clinicians, from a personal perspective, the mind set of someone with an eating disorder. Recovered clinicians can confront and challenge clients while empathizing in a deeply connected and personal way with the client’s fear of giving up the disorder. A recovered clinician is unlikely to encounter resistance that comes in the form of common refrains such as, ‘You just don’t get it’ or ‘Unless you’ve been there, you can’t understand.’ Over the last three decades I have hired and trained countless recovered clinicians to work with me at various levels of care, all the while receiving consistent reports from clients and families that working with a recovered therapist was a significant factor in their treatment success.”
Though there is little research on the topic, informal surveys and interviews pointed out that eating disorder patients felt that exposure to people with recovery, those who understood the illness or have recovered, was or would have been beneficial (Eivors, Button, Warner, & Turner, 2003; Redenbach & Lawler, 2003). In “Been There, Done That,” Costin and Johnson (2002) delineated advantages and disadvantages of clinicians with personal recovery and concluded that advantages outweigh the disadvantages thus “organizations need to acknowledge the useful contributions these clinicians can make to the field” (p. 303). Eleven years later, using qualitative and quantitative methods, Warren, Schafer, Crowley, and Olivardia (2013) revealed many similar benefits of utilizing therapists with eating disorder histories such as increased relational understanding, empathy, and knowledge of the disorder.
A recent and significant contribution by de Vos, Netten, and Noordenbos (2015) came from a survey at their clinic, Human Concern, where they examined both patients’ and clinicians’ experiences of treatment when the therapist was a self-disclosing, eating disorder-recovered clinician. Of the 205 patients who responded (out of 357), 97% indicated that the experiential knowledge of recovered therapists was beneficial in the therapy. Advantages included: the patient feels attunement (recognized, understood, and heard), therapy safety (equitable relationship with high levels of acceptance), the therapist seems available (authentic, open, honest), the therapist has enhanced awareness (knowledge and insight) into the eating disorder, and the patient feels increased hopefulness regarding healing and recovery. Overall, 93% of the patients indicated that the therapy provided by a recovered therapist positively influenced their recovery. Of the 32 recovered therapists who worked at Human Concern during the study and who received a mailed questionnaire, 24 (75%) completed the questionnaire. Of these therapists, 100% endorsed the same advantages as those reported by patients’ and additionally listed the following benefits: quickly bolstering therapeutic trust and cooperation in the working alliance, reducing fear and feelings of shame (the clients knew the therapist had been there or some place similar), providing a positive example (role model), having high empathy, and motivating positive change.
Potential Pitfalls of Clinicians with an Eating Disorder History
Along with potential benefits, Costin and Johnson (2002), de Vos and colleagues (2015), and Warren and colleagues (2013) presented very similar potential risks, limitations, and pitfalls that might arise when therapists who have a personal eating disorder history work with eating disorder patients. Costin and Johnson pointed out the risk of relapse and various kinds of countertransference including having narrow views of how recovery takes place and a high sense of personal mission that could lead to over-involvement. De Vos and colleagues reported potential concerns from both patients and therapists. Patients cited the possibility of making comparisons and becoming overfamiliar with the therapist as a potential negative of therapist self-disclosure, and clinicians noted potential disadvantages as increased projection, over-identification (based on personal versus client experience), and risk for over-involvement or closeness with the patient. Warren and colleagues cited clinician-related potential risks as: over-identification or biases from personal history, countertransference, and experiencing feeling triggered, which can result in setbacks or relapses for some.
Relapse concerns were highlighted by Barbarich (2002), where 27 out of 97 (28%) of eating disorder professionals with a history of an eating disorder reported relapse after entering the field as a professional. However, there are important questions to ask about this study: 1) Were these therapists “recovered,” did they describe themselves as recovered? 2) Did the therapists have at least two years of being recovered before working in the field? 3) How many of these therapists kept their personal histories concealed from colleagues and/or patients? 4) How many of these clinicians received guidance or supervision in how to appropriately use their history in their work? Of note here is that Carolyn has worked with recovered clinicians in various treatment settings for 30 years. Adhering to hiring clinicians who consider themselves recovered for at least two years and providing consistent guidance and supervision has resulted in only one known case to date where a recovered staff member relapsed.
Clarification of Terms
Many people think that the terms “recovery,” “recovering” and “recovered” are just semantic and do not make much difference. We respectfully disagree. When related to how people might view clinicians with eating disorder histories, these terms can be confusing.
Early on in the eating disorder field, professionals and patients started applying the 12 Step program, disease model of addiction, and corresponding language to the treatment of eating disorders. Though Bill Wilson included the term recovered in the Big Book of Alcoholics Anonymous, substance abuse and chemical dependency circles rarely use it and more widely utilize two other terms, recovery and recovering. However, these terms become vague and ambiguous when applied to eating disorders. To say, “I’m a recovering alcoholic” or “I’m in recovery from alcoholism,” typically means the person is notdrinking and acknowledges a lifelong disease/addiction. When a person with an eating disorder says, “I’m a recovering anorexic” or “I’m in recovery from anorexia,” what does the person actually mean? The truth is, someone who says this can mean any number of things such as, the person is in residential treatment, has just discharged from a treatment program, or has been well and normal weight for 10 years.
We respect that the terms recovery and recovering connect, inspire, and work for many. Our hope is for the eating disorder field to come up with a clear and accepted definition of recovered that denotes a person who is no longer engaging in symptoms or suffering from the illness. If clearly defined, the term recovered could be unifying and helpful to clients, practitioners, researchers, and carers alike.
Though there is no consensus, most people would likely agree that to be “recovered” from an eating disorder, there must be an absence of clinically diagnostic behaviors. However, many would also likely agree that this alone is insufficient. What if someone’s only symptom is purging once or twice every other week? Even though the person’s behaviors would not meet diagnostic criteria, most could agree that calling such a person recovered would be incorrect. Likewise a person who is abstaining from overt symptoms while restricting calories, fighting the urge to purge, weighing and body checking multiple times a day, and/or unable to eat with others or in restaurants should not be considered recovered.
Carolyn, who has been self-disclosing and using the term recovered for over three decades, knew it was important for her to define what she meant by the term. Her definition can be found in her books, 100 Questions and Answers About Eating Disorders and the 8 Keys To Recovery From an Eating Disorder:
“Being recovered is when the person can accept his or her natural body size and shape and no longer has a self-destructive relationship with food or exercise. When recovered, food and weight take a proper perspective in your life and what you weigh is not more important than who you are; in fact, actual numbers are of little or no importance at all. When recovered, you will not compromise your health or betray your soul to look a certain way, wear a certain size or reach a certain number on the scale. When you are recovered, you do not use eating disorder behaviors to deal with, distract from, or cope with other problems.”
Both authors have repeatedly experienced clients who come to us after years of struggling with an eating disorder. These clients often report finding both motivation and a sense of hope in knowing that we were once seriously ill but are now recovered. Exposure to those who are recovered, whether clinicians, friends, celebrities, speakers, etc., is important for anyone who has an illness as it provides real proof that being recovered is possible.
Though we firmly believe that clinicians who are recovered from an eating disorder can be in a unique position, we acknowledge complexities that can come from how self or others determine when a clinician is “recovered enough” (Bloomgarden et al., 2003) to safely work with clients who have eating disorders.
How can we know when a person is really recovered? In “Eating Disorder Counsellors With Eating Disorder Histories: A Story of Being ‘Normal,’” Rance, Moller, and Douglas (2010) commented on and critiqued information gleaned from interviews held with therapists who had personal eating disorder histories. The theme of an “emphasis on normality” (p. 382) emerged, meaning that the therapists repeatedly stressed the message that “I am normal” (p. 385) in regard to food, weight, and body attitudes and that their work with eating disorder clients didn’t affect these attitudes. Examples included being free of their eating disorders (“When I got better”), eating normally (e.g., “I’m comfortable about eating”), and body acceptance (e.g., “I’m really ok with my body . . . I don’t mind its changes”) (p. 384-385). The authors added that the clinicians’ expressions generally contradicted research (Shisslak et al., 1989; Warren et al., 2009) indicating that it could actually be more normal to have their attitudes on food, body and weight impacted when working with clients with an eating disorder. Statements made that emphasized normality were originally explained as “adamant assertions” that involve “denial” (p. 389). Fortunately the authors considered an alternative interpretation—that recovered clinicians likely have worked through body, weight, and food issues and have thus “developed a far healthier relationship with these issues” than much of the population (p. 389).
Alli ; “I remember when I first began as a Mental Health Worker at Monte Nido; a miscommunication happened that led to a meeting with Carolyn to discuss and assess my recovered enough status. Not knowing what to express that would ameliorate or clarify the concern, I said, ‘I think this is like the situation where a sane person is accidentally admitted into a psychiatric ward, and anything that person says is not going to be helpful. If it’s OK with you, just watch me.’ I knew that time and observation, not words, would reveal whether I was recovered. And yes, I admit that having self-disclosed my recovered status at work added a layer of stress in that I felt ‘watched,’ but the benefits of being able to train at Monte Nido and harness how to use my past eating disorder experience in helpful ways far outweighed the time limited period of anxiety.”
Even if the field reaches its consensus on a definition of recovered—and then holds it up as the criteria for being able to be work with eating disorder patients—how would we verify a recovered status? Could standardized measuring and monitoring happen? When substance abuse facilities hire individuals who identify as recovering alcoholics or drug addicts, drug testing can verify if the person is considered clean and sober or “using.” There is no similar test to determine if a person is “using” his or her eating disorder symptoms. Some have suggested that therapists with personal eating disorder histories be subjected to clinical eating disorder assessments and ultrasound checks for ovarian size to determine if they are at a healthy weight (Wright & O’Toole, 2005). Without even discussing the actual merit of these as determining factors, would these tests be administered to all therapists who wish to work with eating disorders or just those who say they once had an eating disorder? And couldn’t those with an eating disorder history be able to avoid such testing by not disclosing they ever had an eating disorder?
Other suggestions have ranged from ongoing assessments of the recovered clinicians’ relapse potential, how they conduct therapy, and a myriad of other “indicators.” Some have recommended that for clinicians with an eating disorder history the following should be regularly assessed: absence from work, inability to make decisions or cope in emergencies, seeking therapeutic relationships with colleagues, potential risks to patients, and potential to collude with the patients and their illness. After almost thirty years as clinical director of eating disorder day treatment, residential, and hospital programs, it is noteworthy that Carolyn has not seen higher incidences of problems in any of these areas with her recovered staff verses her staff with no eating disorder history. It seems interesting and confusing that there could be so much proposed attention on therapists who have recovered from an eating disorder but not for therapists who have histories of depression, anxiety, post traumatic stress disorder, or another diagnosis in their past. We leave readers to ponder that question.
The Downside of Not Telling
There is another important consideration here that is seldom discussed. Clients often directly ask their eating disorder therapist whether he or she ever had an eating disorder. Is not disclosing an eating disorder history a risk-free option?
Bloomgarden (2000) noted that when she was treating eating disorder patients and actively withholding her own eating disorder recovery, a barrier was created that negatively affected her working alliance with patients. Others have acknowledged the same was true for them. For example, over the last few years eating disorder physician, Dr. Mark Warren, has been speaking to audiences about clinicians and recovery after finally revealing his own eating disorder history on a panel with Carolyn at a national conference. Dr. Warren told the audience that not disclosing his eating disorder history to patients and their families became so distressing that it undermined his sense of integrity and finally caused him to disclose his eating disorder past.
What Else to Consider
The implications surrounding therapists’ personal disclosure are far reaching and involvea myriad of considerations that cannot possibly be covered in this article. Considerations include: clinical issues; ethical concerns; legal ramifications; human resource management; hiring policies; training and supervision; countertransference problems; self-disclosure guidelines; potential and actual relapse red-flags and concerns; and necessity for research on the pros and cons for both client and clinician, including outcome studies.
Clinicians with a personal history of an eating disorder should be able to make their own decision about whether or not to work with eating disorder patients and whether or not to disclose their personal history. Some colleagues practice a “tell only when asked” policy, meaning they share only if asked by patients or colleagues. Some choose not to share at all, and some share as a routine part of their work. Our ultimate goal is to explore how clinicians with a personal history—who want to use it in their work—can best do so while also recognizing the many related complexities.
Without the existence of widely accepted guidelines that can help eating disorder clinicians to effectively use self-disclosure and personal eating disorder experience, the only guiding ethical cornerstones that exist are to do what is in the best interest of the client and do no harm; however, determining what these mean is up to each individual. For now, any clinician considering self-disclosure, will have to rely on introspection, colleagues, training, professional ethics, consultation, tenets of their dominant theoretical orientation, client feedback, and supervision or employment policies.
In the hopes of generating further discussion and assisting clinicians with an eating disorder past, a second article will be devoted to guidelines for self-disclosure and how to use one’s eating disorder history when working with patients.