Introduction

Many therapists choose their career in part because of personal struggles [1, 2] and wish to give back to others after overcoming such challenges. There are large variations in reported statistics around the incidence and prevalence of past and current mental health issues amongst clinicians. For example, between 35 and 76% of therapists may have experienced depression [3,4,5]. While some have reported that up to 75% of clinicians across mental health fields have received psychiatric treatment [6], such studies are plagued by low response rates. Wide variation in reported rates and methodological issues reveal, in part, the difficulty of assessing mental health amongst mental health clinicians—clinicians may have fears associated with speaking out about their struggles given the stigma that surrounds mental health, even within their own field [7, 8].

Similar challenges exist within the ED’s field in terms of assessing the extent to which people treating EDs have past or current eating distress, and there are wide variations in reported ED history amongst ED professionals. For example, only two of 800 therapists surveyed by Pope and Tabachnick [5] mentioned having experienced an ED. Yet within the ED field, a significant minority of clinicians report having experienced the disorders they treat [9,10,11,12]. Estimates of lifetime ED prevalence among ED providers range from 1/4 [13] to almost half [14]. A survey of 298 ED treatment providers found that 47% (n = 139) reported a personal ED history [14].

Debates abound regarding whether, when, and in what ways recovered ED clinicians should practice. Whereas little research has focused on this population, the existing literature raises phenomenological, clinical and ethical questions concerning therapists with “lived experience” [15] of an ED [16,17,18,19,20]. There is an ongoing debate about whether and when it is appropriate, advisable, or even mandatory for therapists to self-disclose to clients about a personal ED history [16, 21, 22], and decisions about therapist disclosure differ between schools of psychotherapeutic thought. For example, psychodynamically-oriented therapists tend to disclose less often than feminist, humanistic or cognitive-behavioral therapists [23]. Opinions are also divided about the right of ED clinicians to withhold information about their ED history from employers, and whether employers are ethically permitted, or even obliged, to ask potential employees about an ED history [9, 13, 16, 20]. While some employers actively recruit ED clinicians with a personal ED history, others refuse to hire them [16, 20]. Furthermore, the lack of a consensus definition of recovery from ED [18, 24] makes it unclear when people with EDs are “recovered enough” to practice.

Norcross and Farber [25] reflected on how treatment provision by therapists with a personal ED history might be framed as either a problematic desire for self-healing or a positive, mature desire to give to others. Zerubavel and Wright [26] discussed the concept of “wounded healer”, a Jungian archetype “that suggests that healing power emerges from the healer’s own woundedness” [26 p.482]. Although they framed the “wounded” status as a strength, they pointed out that stigma, shame, and silence can be reinforced by seeing the “wounded” status as an impairment to practice. Within the ED field specifically, we continue to see the aforementioned debates about the appropriateness of those who might be framed within that “wounded” optic treating clients with EDs [10, 27]. Perceived advantages of having recovered clinicians practicing in this space include increased capacity for empathy, and instilling hope [10]. Disadvantages include relapse [28] and a tendency to over-identify with clients [19]. Johnston et al. [10] examined the beliefs, attitudes and opinions of ED patients, carers, and ED therapists towards ED clinicians with lived experience. All 32 ED therapists with lifetime ED, but only 46 out of 64 (71.9%) without, believed it was appropriate for ED clinicians with an ED history to treat clients with these disorders [10]. Patients and carers saw the experience of an ED as predominantly positive, whereas clinicians tended to perceive fewer advantages and adopt a stance that was neither positive nor negative. Recovery experiences of clinicians might be used in therapy, for the benefit of the patient, as has been done in the Netherlands (e.g. [29]).

Several recent studies explore attitudes toward ED clinicians with an ED history, especially attitudes of clinicians treating these disorders [29, 30]. Therapist self-disclosure about recovery from an ED has been found to give patients hope and strengthened the therapeutic bond [31]. A survey of 205 ED patients found that 97% pointed out advantages of experiential knowledge, including empathy, safety, insight, authenticity and hope [29]. Barriers and stigma from clinicians may, therefore, be impeding a potentially helpful element of treatment.

In our study, we elicited the perspectives of over 500 clinician and non-clinician members of professional international and national ED organizations towards ED treatment providers with lived experience through an online survey. Specifically, survey respondents were asked about the advantages, disadvantages and limitations of a personal ED history for clinicians and about implications for the employment of clinicians with an ED history. Open responses were analyzed, and multiple-choice responses were compared between: (1) clinicians and non-clinicians in the field of EDs; and (2) respondents with and without a personal ED history. Attitudes were explored and it was hypothesized that (1) attitudes of non-clinicians will be more positive attitudes than those of clinicians; (2) attitudes of respondents with a personal ED history will be more positive than those without.

Methods

Participants

A survey (see Table 3 in “Appendix”) was sent to ~ 3000 members of ED organizations: the Academy for Eating Disorders, the International Association of Eating Disorder Professionals, the Binge Eating Disorder Association, the Michigan Academy of Nutrition and Dietetics, and the Israel Association for Eating Disorders (IAED). The survey was completed by ~ 17% of the link recipients (~ 509 individuals) aged 41.5 years (SD = 13.05, range 18–76). Most were female (91.4%, n = 470) and clinicians (75.6%, n = 385; mean length of practice 3.3 years, SD = 1.6): Social workers (n = 71), clinical psychologists (n = 115), physicians/psychiatrists (n = 28), family/couples therapists (n = 30), dietitians/nutritionists (n = 70), counselors/expressive therapists (art, music and psychodrama therapists; n = 37), nurses (n = 23), and coaches (n = 11). Non-clinicians (n = 124) were advocates (n = 23), students (n = 45), researchers (n = 6) and “other” (n = 50). Respondents were from the US (68.1%, n = 346), other English-speaking countries (8.6%, n = 44; Canada [n = 22], UK [n = 12] and Australia [n = 12]) and Israel (21.4%, n = 109), with 2 respondents from Estonia and one each from Mexico, Latvia, Argentina, the Netherlands, Spain, Switzerland and Costa Rica. Most respondents had a degree (94.9%, n = 488), and reported involvement with the ED field (84.8%, n = 436).

Instruments

Survey

The survey (see Table 3 in “Appendix”) focused on attitudes towards ED clinicians with a personal ED history. Items included (a) demographics (age, gender, country of origin); (b) professional characteristics (profession, degrees, length of practice) (c) personal ED history; and (d) ten questions about clinician disclosure, employer hiring practices, and perceived advantages and disadvantages. Three open questions were included: 1. Respondents who responded “Yes, conditionally” to the question “In your opinion, should clinicians who have recovered (or are in recovery) from an eating disorder be allowed to work with ED patients?” were asked for conditions that would allow this; 2. Respondents who saw advantages to ED treatment by a clinician with an ED history were asked to list them; and 3. Respondents who saw disadvantages were asked to list these.

Procedure

Participants were informed that the survey was about attitudes within the eating disorder treatment and advocacy community towards clinicians with a personal history of an eating disorder. The survey was administered online in January–February 2013 using Qualtrics® (www.qualtrics.com). The study was approved by the Internal Review Boards of the University of Michigan and Ruppin Academic Center in Israel. Informed consent was obtained on the first screen. Multiple choice responses from clinicians with and without a personal ED history were compared with responses from non-clinicians with and without a personal ED history. Statistical analyses were conducted using SPSS, version 23. Statistically significant between-group differences were tested with χ2 tests with a Bonferroni correction (i.e. p-value multiplied by the number of questions [10] should still be below 0.05). Post-hoc analysis were only performed when the overall test was statistically significant. A Z-test was performed with Bonferroni adjusted p-values for the categories of answers for the post hoc analyses.

Open questions were examined using thematic analysis, to identify patterns in the responses speaking to themes relevant to the research aims [32]. RBM and JADV independently conducted the six-phase analyses [32]: 1. Reading responses; 2. Generating initial codes; 3. Systematically searching and labeling potential themes and codes; 4. Reviewing themes and codes; 5. Finalizing names and clear definitions for themes; and 6. Reporting the most frequent, relevant themes. Differences were discussed and resolved, together with AHZ, until a final set of consensus themes was reached [33].

Results

Almost half of the respondents (47.2%, n = 240) reported a lifetime ED diagnosis (i.e., diagnosis of at least one ED in their lifetime), with 121 reporting anorexia nervosa, 94 reporting bulimia nervosa, 77 reporting binge eating disorder, and 108 reporting “another” ED (respondents could report a history of more than one ED). Of the 385 ED clinicians surveyed, 153 (39.7%) reported a lifetime ED diagnosis (25 with a current/active ED, 128 being recovered from a past ED). Of the 124 non-clinicians, 87 (71.8%) reported a lifetime ED diagnosis (46 with a current/active ED, 41 being recovered from a past ED).

Quantitative, multiple choice responses

Table 1 presents comparisons between the categorical responses of clinicians with (n = 153) and without (n = 218) an ED history and non-clinicians with (n = 87) and without (n = 34) an ED history.

Table 1 Survey responses: major group differences
Full size table

In general, attitudes did not differ significantly between clinicians and non-clinicians. Multiple choice responses of clinicians without an ED history tended to differ from responses of the other groups. Below are brief explanations of the between-group differences presented in Table 1:

  1. 1.

    In response to the question asking whether clinicians who are recovered from a past ED should be allowed to treat ED patients, the vast majority responded either “yes” (44.3%) or “yes, conditionally” (46.5%). Clinicians with no ED history were significantly less likely to respond “yes” than clinicians and non-clinicians with an ED history (34.1% vs 51%, 54.7%), and more likely than non-clinicians with an ED history to respond “not sure” (11.1% vs 2.6%).

  2. 2.

    In response to the question asking whether clinicians who have a current/active ED should be allowed to treat ED patients, the majority responded “no” (65.9%). Regarding statistically significant group differences, “yes” responses were more frequent among non-clinicians with an ED history than among clinicians with no ED history (10.3% vs 1.4%).

  3. 3.

    In response to the question whether clinicians recovered or in recovery from an ED should disclose their ED history to their clients, most respondents (64.4%) thought they should, “when appropriate”. Clinicians with no ED history replied “when appropriate” significantly less often than clinicians with an ED history (54.8% vs 76.2%), “no, never” significantly more frequently than non-clinicians with an ED history (16.1% vs 4.7%), and “not sure” significantly more frequently than clinicians and non-clinicians with an ED history (22.6% vs 10.6%, 8.1%).

  4. 4.

    In response to the question whether clinicians recovered or in recovery from an ED should disclose their ED history to employers, most respondents (59.4%) thought they should “when appropriate”. There were no significant differences between groups.

  5. 5.

    In response to the question whether employers should be allowed to ask potential employees /clinicians if they have a personal ED history, approximately half the participants responded “yes, always” (12.5%) or “yes, if appropriate (34.4%), 37.5% responded “no” and 11.9% “not sure”. Clinicians with no ED history responded “yes, always” significantly more often than clinicians and non-clinicians with an ED history (26.4% vs 10.6%, 9.2%). Non-clinicians with an ED history responded “yes, if appropriate” significantly more often than clinicians with no ED history (51.7% vs 29.6%) and “no” significantly less often than clinicians with an ED history (24.1% vs 42.4%).

  6. 6.

    In response to the question whether employers should be allowed to ask potential employees /clinicians if they have a personal history of any mental illness, almost half the participants responded “yes, always” (18.5%) or “yes, if appropriate (34.8%), 34.8% responded “no” and 14.9% “not sure”. Non-clinicians with an ED history responded “yes, if appropriate” significantly more frequently than clinicians both with and without an ED history (50% vs 27.8%, 31,3%). They also responded “no” significantly less frequently than clinicians with an ED history (24.4% vs 38.7%).

  7. 7.

    Fully 81.1% of the participants responded in the positive to the question of whether there are advantages to ED treatment by a clinician with an ED history. Clinicians with no ED history answered in the positive (“yes”) significantly less often than both clinicians and non-clinicians with an ED history (67.8% vs 92%, 95.3%).

  8. 8.

    Fully 87.1% of the participants responded in the positive to the question whether there are disadvantages to ED treatment by a clinician with an ED history. There were no significant differences between the groups.

  9. 9.

    In response to the question whether employers should actively encourage the hiring of clinicians with a personal history of an ED, approximately half the participants (51%) responded “no”, 16.2% replied “yes” and 32.6% “not sure”. Clinicians with no ED history responded “yes” significantly less frequently than clinicians with an ED history and non-clinicians with and without an ED history (4.2% vs 26.5%, 57%, 30%). They responded “no” significantly more frequently than clinicians and non-clinicians with an ED history (73.7% vs 37.1%, 23%).

  10. 10.

    In response to the question of whether employers should actively discourage the hiring of clinicians with a personal history of an ED, the vast majority of participants (81%) responded “no”. Clinicians and non-clinicians with an ED history responded “no” significantly more frequently than clinicians and non-clinicians without an ED history (92%, 90.8% vs 71.4%, 66.7%). Clinicians with no ED history responded “yes” significantly more frequently than clinicians with an ED history and non-clinicians with and without an ED history (11.3% vs 0%, 1.1%, 3%). Non-clinicians with no ED history responded “not sure” significantly more frequently than clinicians and non-clinicians with an ED history (30,3% vs 8%, 8%).

Qualitative, open responses

Themes identified in the thematic analysis of open responses are summarized in Table 2.

Table 2 Overall themes with a short explanation of the qualitative analysis and examples
Full size table

Notably, participants articulated that there were both positives and potential pitfalls associated with those in ED recovery working with clients with EDs. Participants articulated the timeframe and psychological work associated with becoming an effective ED clinician following one’s own ED. They suggested that working in this space required ongoing training and supervision to help navigate any challenges that could emerge. A therapist who is able to take on this work, according to participants, would be one who was self-aware, and who had received treatment that helped them reach a state of recovery prior to becoming an ED clinician and/or while practicing.

Participants suggested that having an ED history can lend the clinician experiential knowledge that they would not have been able to obtain elsewhere. Similarly, these clinicians were described as having the capacity to be empathic and non-judgmental, leading to the potential for a strong therapeutic alliance with the client. Trust in therapeutic relationships might be enhanced by openness around lived recovery experiences, according to participants. Clinicians with an ED history may also be received as hopeful symbols of the possibility of recovery and/or as positive role models.

Conversely, some participants described the potential for clinicians with an ED history to “lack objectivity”, identifying the potential for unconscious transference and countertransference and/or assumption-making about the client’s pathway to recovery. Concerns were articulated around the potential for a lack of objectivity with either party in the therapeutic relationship. Further, participants identified that some actions on the part of the clinicians (such as self-disclosure) may be received negatively if the clinician is not perceived to be in solid recovery. Finally, participants discussed the potential for boundaries to become blurred within the therapeutic relationship and/or for competition and comparison to arise.

Discussion

In our survey of over 500 ED clinicians and non-clinicians recruited via five national ED organizations, participants expressed a wide range of opinions, attitudes and values regarding lived experience in professional practice, reflecting the complexity of these issues and the lack of clarity provided by extant guidelines. Fully 47.5% of the ED clinicians surveyed reported a lifetime history of an ED, as was found by Warren et al. [14]. Since participants in both studies were self-selected, there is a high chance of self-selection bias. Nevertheless, ED therapists reporting a lifetime ED diagnosis undoubtedly constitute an important minority within the ED field, which raises ethical and professional dilemmas.

Respondents in our study were nearly evenly split between those who thought this minority should be allowed to practice unconditionally and those who thought conditions should apply. Under 2% believed they should not be allowed to practice. With respect to the articulated conditions of practice, participants suggested that therapists should:

  1. (1)

    be recovered – although definitions of recovery varied widely;

  2. (2)

    receive training and supervision to use their lived experience beneficially;

  3. (3)

    have high levels of self-awareness to manage potential triggers and boundary issues; and

  4. (4)

    have present or past therapy.

Such conditions are potentially important because of the absence of written policies or guidelines for hiring and monitoring clinicians with an ED history [9]. There is a clear need for further work on the legal and ethical considerations associated with employing clinicians with a past, and particularly a current ED [20, 33]. Moreover, considerations raised by respondents rest in part on the definition of recovery they endorse. In the open responses, conceptions of recovery ranged from having “just a few symptoms” to being completely symptom-free for a decade. This underscores the current disagreement on what constitutes remission, recovery and full recovery from EDs [34] and whether the latter is attainable [35]. The large discrepancies in recovery definitions, and, therefore, in conditions for clinicians with an ED history to practice, also underscores the urgent need for a standardized definition of recovery from an ED, operationalization and measurement strategies [36].

A minority of respondents (15%) reported a current ED. Although this group was not large enough to allow comparisons, it is ten-fold that found by Johnston et al. [10]. Since cognitive capacities [37] and emotional competence [38] necessary for self-evaluation and decision-making may be impaired in people with active EDs, this is complex. Arguably, the professional and ethical dilemmas raised with regards to ED clinicians with lived experience seem more relevant for actively symptomatic clinicians. Regardless of the ethics surrounding the practice of currently ill clinicians, our results indicate this is a reality, and clinicians with active ED symptoms should, therefore, be recognized and supported.

ED clinicians with a lifetime ED need to decide whether and under what circumstances to disclose their ED history to their clients [13]. An overwhelming majority of participants (76%) supported self-disclosure “when appropriate”. This stance seems justified by a study that found that ED patients expressed qualified positive responses regarding their therapists' self-disclosure [29]. Yet patients and therapists felt that too much therapist self-disclosure can harm the therapeutic alliance, contribute to negative transference and countertransference, trigger symptoms and/or invite comparisons between patients and therapists [29].

Approximately 80% of respondents believed that ED clinicians with lived experience of an ED had advantages over others, and the characteristics of these advantages were identified. It was widely believed that lived experience of an ED deepens therapists’ understanding of and empathy for clients and enhances resistance to manipulation. It was also believed that recovered therapists serve as positive role models and inspire hope for recovery. These themes echo the unique advantages described in previous studies [10, 16, 29].

The fact that most respondents perceived lived experience of an ED as being advantageous for clinicians in many ways did not prevent them from simultaneously perceiving disadvantages. In fact, over 85% of respondents believed that ED clinicians with an ED history had disadvantages compared to other clinicians, especially if recovery was tenuous. Disadvantages included a lack of objectivity, assumptions from personal experience, relapse risk, comparison and competition, and blurring of boundaries. Interestingly, the belief that there are disadvantages to treatment by a clinician with an ED history proved the least contentious survey item, with no between-group differences.

Many of the ethical concerns addressed in this study remain to be addressed. For example, when is a therapist with an ED “recovered enough” to treat ED patients and who should decide? How should/could degree of recovery be measured when there is no consensus definition of ED recovery or measurement strategy [18, 24, 36, 39]? What guidelines could be proposed for employers when hiring clinicians with an ED history [20]? How can employers and colleagues ensure safe practice and adequate support for clinicians in recovery from EDs [13, 27] without increasing stigma against them [40]? Are clinicians with a history of other psychopathologies also prone to specialize in this disorder, and is their competence to treat clients with the disorder they have experienced questioned in the same way? There is a pressing need for research and informed guidelines on these and other issues concerning ED clinicians with an ED history. Despite studies pointing to the need for such guidelines [13, 16, 29], we still have none. Similarly, resources are needed to guide ED clinicians without a personal ED history in their dilemmas and ethical considerations regarding colleagues with a past or present ED.

This study has several limitations. First, the data were collected in 2013 by the “Recovery and Professionals” Special Interest Group of the Academy for Eating Disorders, the changing membership of which caused a delay in analyzing and reporting the results. Attitudes towards ED clinicians with lived ED experience may have since changed. Importantly, however, the questions raised in the survey still remain unresolved and we still have no clear guidelines for the clinical practice of clinicians with an ED history. Second, the ED diagnoses of respondents were self-reported, so may not have been entirely accurate. By distinguishing between a ‘current’ and ‘past’ history of an eating disorder, our survey did not take into consideration that recovery is a process, and that there may be variance between categorical ED self-diagnoses. Third, response rate was low, so selection bias seems likely. The survey was presented as being about attitudes towards clinicians with a personal history of an eating disorder. It was written and initiated by members of the “Recovery and Professionals” Special Interest Group of the Academy for Eating Disorders, and many members of this SIG with an ED history completed the survey. Participants, therefore, no doubt included an overrepresentation of respondents with a history of ED and people with strong feelings and opinions about ED clinicians with an ED history.

Our study adds to the literature about ED therapists with lived experience by elucidating differences between the viewpoints of clinicians and non-clinicians with and without a personal ED history towards fitness to practice, self-disclosure, hiring practices and (dis)advantages of a personal ED history. These viewpoints have the potential to inform future guidelines, for example by suggesting that to practice, ED therapists with a personal ED history should be in solid recovery, receive training and supervision, and be encouraged to receive therapy to increase self-awareness. In addition to informing future guidelines, these insights into how clinicians with an ED history view themselves and are viewed by others should be used on a national and international level to help combat stigma, promote openness and dialogue, encourage the adoption of a consensus definition of recovery, and help develop an informed approach towards the employment of ED clinicians with an ED history.

What is already known on this subject?

ED therapy by clinicians with a personal ED history raises ethical and clinical dilemmas. Little is known about the advantages, disadvantages, limitations, support and employment of such therapists.

What this study adds?

Opinions about ED clinicians with an ED history vary and some place conditions on their practice. They are widely seen as competent, with both advantages and disadvantages over other ED clinicians.