|The Use of Clinicians with Personal Recovery in the Treatment of Eating Disorders
Craig L. Johnson, Ph.D.
Director, Eating Disorders Program
Laureate Psychiatric Clinic and Hospital
Professor of Clinical Psychology
University of Tulsa
Carolyn Costin M.A. M.Ed
Director, Monte Nido Treatment Center
Director, The Eating Disorder Center of California
As the field of eating disorders matures, it becomes increasingly incumbent upon us to tackle thorny issues that have received little or no formal attention up to this point. One of these issues is the role for clinicians who have personal recovery from eating disorders in the treatment of this patient population. The issue has far reaching implications -- from delicate human resource management laws to subtle counter transference questions regarding the use of self-disclosure in psychotherapy. The task of this article will be to open a broad-based dialogue in hopes of having an evenhanded and productive discussion of the relative advantages and disadvantages of having clinicians with personal recovery involved in the treatment process. The eventual goal would be for our field to offer guidelines regarding this issue.
Existing Data Base Regarding Guidelines
Through basic inquiry and research neither author has been able to find written guidelines from any eating disorder organization or treatment program regarding clinicians with personal recovery treating eating disorder patients. Overall, it appears that our field has not formally addressed the issue.
Large Program's Experience and Informal Positions
In an effort to gather some data, ten established programs in the Untied States were contacted to explore their experience and current position regarding the use of staff members with personal recovery. Of the ten programs, five were not for profit and five were for profit. None of the programs had written policies or guidelines regarding the hiring or monitoring of staff who had personal recovery. All of the program representatives mentioned the potential legal issues related to the American Disabilities Act. Four of the programs actively embraced hiring staff with personal recovery, five programs were mixed (meaning that personal recovery was not a hiring consideration one way or the other) and one program actively avoided the hiring of clinicians with personal recovery. Among the four programs that embraced hiring staff with personal recovery, the estimates of staff with recovery ranged from approximately 30% to 80%, although none of the sites had specific numbers or any formal definitions or criteria for recovery or relapse. They also did not have specific mechanisms for monitoring the individual's recovery. Reassuringly, two of the sites informally had two-year recovery criteria and two sites had one-year recovery criteria. Recovery was loosely defined as normal weight and abstinence from bingeing and purging. Interestingly, and probably appropriately, the clinical leaders of these programs were more concerned about these particular staff' members' overall comfort with their size and shape. This appeared to be a bell-weather issue, but once again guidelines or criteria for monitoring were fuzzy at best.
Although the lack of formal guidelines and criteria in the programs, was disappointing, the level of awareness and overall thoughtfulness regarding the clinical and legal issues related to this topic was impressive. All of the programs were interested in receiving guidelines from our professional organizations.
None of the programs surveyed had data on staff relapse rates. Among the programs that actively embraced hiring staff with personal recovery, estimates of relapse ranged from 0 to 20 percent. The program that actively avoided hiring recovering staff had recruited staff with recovery in their early years and had reversed positions over the last few years. They estimated that 75% of their recovering staff had relapsed while working at the treatment center. (It would be important in further study of this issue to ascertain what constituted relapse and how they came up with that estimate). In talking with the leadership of that program, it was unclear why the relapse rates were high in relationship to other programs.
Laureate Experience by Craig Johnson
When I began developing the Eating Disorders Program at Laureate, I actively recruited staff that had personal recovery. This was an effort to directly learn what the costs and benefits were of adding this dimension to a treatment program. My goal was to hire a mix of recovering and non-recovering staff of different theoretical perspectives. The theoretical perspectives included Psychodynamic, Cognitive-Behavioral, Feminist, 12 step, Christian and Systems. The task was to experiment with integrating these different models of recovery. I am pleased to report that it has been an interesting and productive exploration.
Over the last ten years, 11 staff with personal recovery have worked in our program. This included two PhDs, six Masters prepared Licensed Therapists, one RN and two psychtechs. Overall, these clinicians have made an unusual and outstanding contribution to the program. The fact that we have staff with recovery is consistently mentioned in patient satisfaction surveys as one of the strengths of the program.
From my perspective, the benefits have outweighed the cost, but there have been problems along the way. Among the eleven recovering staff that we have had over the ten-year period, three wobbled with their recovery, one had what I would regard as a moderate relapse and one had a profound relapse. The three staff that wobbled did not relapse behaviorally, but reported feeling psychologically vulnerable. This resulted in a modest intensification of supervision and this vulnerability abated within several weeks in all three cases. The one moderate lapse included a behavior relapse that resulted in the staff receiving some outpatient therapy. The behavioral relapse was remedied in several weeks. During this time, we decreased the staff's direct patient contact and then gradually increased the contact once the behavioral relapse was remedied. The staff member who had a serious relapse required residential treatment. This staff member did not return to the program by mutual agreement.
The Monte Nido Experience by Carolyn Costin
Since I began treating eating disorders in 1979 I have always referred to and utilized my own recovery from anorexia nervosa. In fact, my first referral came from a colleague who referred me the client because he knew I had suffered from my own eating disorder and thought this would help me in relating to this young woman. He also told her the same. Therefore, "the cat was already out of the bag" so to speak. Since that day I have been open about my own experience with an eating disorder and I have always referred to myself as being "recovered". This fact has been in my resume, in my books, and in the brochure for Monte Nido. I never actively sought out staff with personal recovery but since Craig began the exploration of this topic I have looked at Monte Nido and had to ask why, at Monte Nido, with a total staff of 30, are 22 recovered from an eating disorder? And out of my therapists, dietitians and support counselors, why 85% are recovered from an eating disorder? . I have two main answers to these questions. First, I think that therapists with recovery seek out positions in this field but most don't usually feel safe revealing their personal history. This has been discussed recently at several conferences and in an article published in the winter 2000 issue of "Eating Disorders, The Journal of Treatment and Prevention" .by Andrea Bloomgarden. I have never asked anyone about personal experience with an eating disorder in an interview. However, since my own recovery is public people feel comfortable revealing their personal recovery to me. Therefore, it may be that other treatment programs have higher rates of staff with recovery but don't know it. In fact, I have had a number of staff who, prior to working at Monte Nido, worked at other centers never revealing their past history of an eating disorder. These staff members expressed relief in not having to keep their recovery a secret at Monte Nido. Secondly, I must consider that even though I am not aware of partiality when interviewing, there is probably something about certain staff members with personal recovery that helps them be selected by me for a position. It is not recovery alone that I'm drawn to, as I have interviewed many people with an eating disorder history whom I did not hire. I am drawn to someone who has made peace with food and body issues and sees their eating disorder as a thing of the past. It truly is a "been there done that, not intimidated by it, I made it so can you", attitude, that I am attracted to in potential staff. These people seem to exude confidence in understanding and dealing directly with the eating disorder symptoms of patients. They offer hope and inspiriation that individuals with eating disorders can become fully recovered.
At this point it is important to point out that there are two ways of referring to people with personal recovery. Some describe themselves as "recovering" and others consider themselves "recovered". There are no universally accepted definitions for these terms. In 12 Step programs the commonly used term for people in recovery is "recovering." One problem with this term is that it can apply to people in various stages of recovery and even to those who are still having problems with eating disorder behaviors. "Recovered" is a term used by individuals who feel that it is possible to fully overcome an eating disorder and leave it behind. The problem with the term "recovered" is how to define it and who decides when an individual has reached this state.
At this point I can't imagine the treatment at Monte Nido without the important component of having recovered staff members. I have found no more problems with them than with staff members who do not have an eating disorder history. Supervision is provided for all kinds of counter-transference and personal issues.
I know of only two staff members in five years who left Monte Nido due to the fact that they felt "uncomfortable" and even "triggered" by the patients. I have seen no evidence of relapse back to an eating disorder. One other staff member who had an eating disorder history and a history of another DSM diagnosis, relapsed into her other diagnosis but not her eating disorder.
How Prevalent Are Eating Disorders Among Professionals Who Specialize in the Field
Unfortunately, there has been little systematic study of the nature and extent of eating disorders among professionals in the area. One study is in the process of being completed by Bloomgarden, Gerstein and Moss (Personal Communication). They surveyed 150 staff members of a large treatment program regarding self and/or family history of eating disorders. Forty-three percent of the respondents reported having personal experience with an eating disorder. Twenty-nine percent had struggled with one themself and fourteen percent had a family member with an eating disorder. Of those who reported a personal history of eating disorder, 84% had received treatment. None of these staff were currently in treatment and the average length of time since they had had the disorder was 11.6 years. Interestingly, the site of the survey was one of the programs that Craig had interviewed. They fell into the neutral category regarding hiring staff with personal recovery, meaning that they neither openly embraced nor rejected individuals with a history of eating disorders.
It is important to note that this neutral position would be in compliance with the American Disabilities Act. The dilemma that is created by the American Disabilities Act is that it appears that conservatively about 30% of staff that work in specialized treatment settings have personal recovery. The neutral position cited by the American Disabilities Act creates an atmosphere that errs in the direction of a "don't ask, don't tell" mentality. The danger of this is that if staff is struggling, it makes it more difficult for them to ask for help.
Clinical Advantages of Staff with Recovery
Understanding, hope and motivation
Many of our patients, after years of struggling with the illness, are exhausted, defeated and quite hopeless. These are predictable side effects given that the outcome literature suggests that if a patient does not respond quickly to treatment in the first year, then recovery can become quite protracted. Strober, (1997), in an elegant long-term outcome study, reported 21% of patients who had received a complete treatment at their center, had partial recovery and 1% had full recovery two years after discharge. It wasn't until the 4-year mark that patients began showing significant improvement with 55% in partial recovery and 18% in full recovery. The rate of recovery continues to accelerate until the eighth year, when 80% are in partial recovery and 67% are in full recovery. This data demonstrates that the course of recovery can be quite long and tedious.
Staff who have successfully accomplished recovery are often able to quickly establish that recovery does occur and that one can lead a stable and productive life. Recovered staff members are able to become a concrete representation of the "light at the end of the tunnel." Words can often be too abstract when patients are completely overwhelmed and defeated by the illness. Clinicians who have successfully mastered recovery become a living, breathing example that recovery is attainable. Clinicians who have not walked this valley simply do not have as much creditability. Former patients in both of our programs consistently report that one of the most important aspects of our programs is the hope and motivation they experience from the staff members who "have been there".
Empathy and Trust
There is no substitute for having "stood in someone else's shoes" for facilitating empathy. As a former athlete Craig has a first hand understanding of the challenges of managing fear of failure, anxiety and the effects of adrenaline when in a "clutch" situation. If you have not been in that situation, it can be difficult to explain the profound interactions that occur. Likewise, it is difficult for staff members who have had no personal experience with an eating disorder to fully grasp the profound struggle that recovery can pose for individuals. Recovered staff members achieve the rapid development of rapport, which is the bedrock of trust. Trust is absolutely crucial with our patients because we are often dealing with a phobic-like fear of change. Our patient's ability to recover often requires them to take a "leap of faith." They are asked to take risks that feel catastrophic.
Engaging the patient in a trusting therapeutic relationship is not the greatest challenge for staff who have had eating disorders themselves. They usually accomplish this more quickly than the other staff members. Their large challenge is usually guiding the patient's recovery in a manner that allows the patient to write their own version of recovery. It can sometimes be difficult for someone who has experienced recovery to realize that there is not a single truth about how to recover. This will be addressed more fully in the disadvantage section that follows.
Many of our patients have created false selves that cover what they feel is their shameful underbelly. They fear that if others discover the full extent of their primitive thoughts, feelings and actions they will recoil in horror and disgust. Ultimately, the patient fears he will be abandoned as worthless and defective. When patients see recovered clinicians being valued and occupying positions of status within treatment programs, it can be powerful. It can send a message that individuals who have had eating disorders can expose these shame-filled aspects of themselves, master them and then use the experience to consolidate a more authentic self system that can be valued by others. Both authors agree that this invitation to become more authentic by staff members who have openly and successfully confronted this issue is one of the most powerful experiences that we see occur in our treatment settings.
Challenging narcissism and grandiosity
There are many roads to self-centeredness. Some of our eating disorder patients arrogantly wear their illness like badges of honor. Unconsciously, if not consciously, they enjoy the competition and "oneupsmanship" around issues of size and shape. This is a subgroup of patients that can often "hook" staff and provoke them into nonproductive counter transference acting out.. Recovered staff seem to be better at confronting and bending these patients self-centeredness towards greater humility and community service. Understandably, these staff members seem to be given greater license by the patients to confront this grandiosity and self-centeredness.
A subtle, but equally pernicious form of self-centeredness can occur with patients who are swamped in despair and hopelessness. Unwittingly, these patients can become so preoccupied with their despair that they begin to drown in self-pity. Staff members who have not experienced this kind of emotional hardship can become too sympathetic and can become immobilized by over identifying with the patient's sad state. Overall, the patient is seen as fragile and tragic. Staff members who have confronted and passed through this process in recovery are usually quick to point out the folly of this way and are less ambivalent about confronting the patient's immobilization. They seem to be given greater license to confront self-pity, helplessness, etc. because they have actually had to deal with it. The direct or indirect message that gets communicated by the staff who have faced, dealt with and overcome their own eating disorder is something like "been there, done that; learned how to manage it and moved on. If I can do it, so can you." As Carolyn stated earlier, this aspect of treatment has become such a profound aspect of turning patients around at Monte Nido that it is hard to now imagine the treatment without it's presence.
A Different Perspective
In a previous manuscript, Craig argued for the importance of actually working with the patient on symptom management strategies while simultaneously listening for and interpreting transference issues (Johnson and Connors, 1987). From our perspective, effective symptom management is best accomplished by moving back and forth between these two tasks. The traditionally trained, non-recovery staff can sometimes become enamoured with the process and underlying dynamics of a patient and neglect the need for symptom improvement (i.e. weight gain, abstinence from bingeing and purging, exercise, etc.). Both authors have found that recovered staff members can be exceptionally effective at reminding the team that it is really hard to grow much psychologically when actively engaged in the thoughts, actions and feelings of the illness. These staff members represent a consistent perspective on the importance of stopping the active practice of the patient's illness while trying to help them understand the underlying dynamics.
The Importance of the Terms "Recovered Vs "Recovering"
The authors of this paper have different opinions on this issue.
Craig Johnson will present his ideas first:
Whenever I present about the issue of staff with personal recovery, I am usually asked whether our treatment program believes that people can fully recover or do we subscribe to the notion that one is always in the process of recovering. Clearly, the outcome data tells us that after ten years about 75% of the patients with eating disorders who have received treatment from outpatient to intensive inpatient will be recovered. This data can be somewhat misleading, however, when you consider that most patients with eating disorders usually carry multiple Axis 1 and Axis II diagnosis. This suggests that patients, who do not respond rather quickly to informed outpatient interventions, are probably dealing with a number of vulnerabilities that will make their life more difficult than the average person. For this subgroup, the concept of recovering is a better fit in that it implies that they will need to actively manage their vulnerabilities through out their lives. Even if their eating disorder symptoms are solved, they may manifest other psychiatric related symptoms over the course of time.
Recovered vs recovering is a somewhat moot point in our program. We usually see our task as being to use the current symptom struggle as an opportunity for the patient to develop a wisdom base that allows them to develop coping strategies that they will use throughout their lives. We see our task as somewhat larger than just recovering from the symptoms of eating disorders.
Carolyn Costin's Perspective:
To begin where Craig left off I will say that of course our task is larger than just helping someone recover from the symptoms of an eating disorder. In fact, this is one reason why I think there is a big difference between the terms "recovering" and "recovered." The way I see it is that one is still recovering when they are working hard at keeping the symptoms at bay. These individuals identify themselves still with the illness, for example, "I am a recovering anorexic" or " I am a recovering bulimic." When one is "recovered" from an eating disorder it feels as though it were a thing in the past that is no longer there. One does not fear relapsing back into the illness because both the symptoms and the underlying issues are resolved. I am speaking here not only from my personal experience of having recovered but also from the experiences of countless patients I have treated who feel exactly the same way. There are other patients of mine who feel they are still "recovering" but hope one day to be "recovered." Also, as Craig mentioned, there are also patients who probably will always be "recovering" due to the severity and length of their illness and other complicating factors. All three of these possibilities exist but to say that the difference between them is a moot point is missing something profound. I agree that it is hard to define when one is recovering or recovered but because it is difficult to define does not mean it does not exist or that it is moot. I feel very strongly that I am not still recovering from anorexia nervosa which I suffered from over twenty years ago. This point is not moot to me. In our treatment programs and in our private practices we may not be able to declare someone as "recovered" because studies now show this process takes a very long time, but it does happen with or without us recognizing or calling it that.
The danger of exclusively using the term "recovering" and hiring staff whom are referred to as "recovering" is that it implies that people can never be "recovered." This idea originates from the addiction or disease model used in Alcoholics Anonymous. In this paradigm eating disorders are thought to be lifelong diseases that can be controlled into a state of remission by maintaining abstinence on a daily basis. According to this viewpoint, if the symptoms go away, the person is only in abstinence or remission but still has the disease, for example, still a "recovering anorexic" Labeling eating disorder patients in this way may not only be a diagnostic trap but a self-fulfilling prophecy. I feel the same way about labeling anyone as an "anorexic" or "bulimic." I try never to use these terms. I prefer to say the person suffers from anorexia nervosa or bulimia nervosa. This implies one can get over the illness and it also helps to avoid over identification with the illness.
How a treating professional views the illness and the treatment will not only affect the nature of the treatment, but the actual outcome itself. Although this may be an extreme example I would like to point out a quote taken from a book subscribing to the 12 Step or disease model; "It is that first bite that gets us into trouble. The first bite may be as 'harmless' as a piece of lettuce, but when eaten between meals and not as part of our daily plan, it invariably leads to another bite. And another, and another. And we have lost control. And there is no stopping" (Overeaters Anonymous, 1980).
I think most clinicians will find this kind of statement troubling. Whatever the original intention, this kind of thinking might more often than not be setting up the reader for relapse, creating a self-fulfilling prophecy of failure and doom.
I want my patients to see models of individuals who are recovered. I want them to believe that this is possible. I am clear to point out that everyone does not achieve this and that recovery can mean many different things and take many different phases. I am clear with my patients about these complex issues and don't try to simplify them. I am also clear that my beliefs and the beliefs of my staff members influence our treatment and our outcomes.
Norman Cousins, who learned firsthand the power of belief in eliminating his own illness, concluded in his book Anatomy of an Illness, "Drugs are not always necessary. Belief in recovery always is." If patients believe they can be fully recovered, they have a better chance of achieving it. I believe all patients and clinicians will benefit if they involve themselves in treatment with this idea in mind.
Risk of relapse
Craig Johnson comments:
The most obvious disadvantage of hiring staff with personal recovery is the risk of relapse. Interestingly, I have never had a non-recovering staff member develop an eating disorder as a result of working with this patient population. As mentioned earlier, however, I have had several recovering staff experience moderate to severe relapses. It has become increasingly clear to me over the years that the risk of relapse is highly correlated with the length of time of recovery and the level of training of the clinician. The longer the time of recovery and the more sophisticated the training, the less likely relapse will occur.
There was a time when I thought that recovering staff should test the stability of their recovery by beginning with treatment of patients on an outpatient basis. I was fearful that the more intensive settings would be difficult. I have subsequently reversed my perspective. I think that the greater isolation that usually accompanies outpatient work, as well as the difficulty with containment of the patients, actually makes outpatient work riskier. I prefer that recovering staff begin in settings where there is ongoing peer contact and the patients are being more highly supervised. I believe the more intensive settings can provide better protection for staff members who are moderately new in their recovery.
Carolyn Costin's comments:
I feel strongly about hiring staff who refer to themselves as "recovered" rather than "recovering" or "in recovery". Once a potential staff member has revealed their experience with an eating disorder I ask further questions on this subject. My unwritten rule for hiring staff members with an eating disorder background is that they should have at least two years of being "recovered" behind them . Staff members at Monte Nido eat with the patients and eat the same food that the patients are served. It is important for staff members to feel comfortable with this situation because if not this could be a problem. I also let potential staff know that they will most likely be asked by the patients whether or not they have had an eating disorder because many of us have self disclosed this fact. I tell all staff that, of course, they do not have to answer this or any other personal question but I want to prepare them because the atmosphere at Monte Nido is such that patients will ask. I also let potential staff come to Monte Nido for a few hours to see what it is like before they actually take a position. This helps both of us see if the position is a good fit. I suspect that due to all of these things I have no known problems with relapse in my staff.. On one occasion a staff member resigned and I heard rumors that she was having problems again with her own eating disorder but I have no way of knowing if this was true. This particular staff member had never revealed to me that she had in the past suffered from an eating disorder. If the rumor is true, I wonder now if she was not recovered enough to feel comfortable discussing it. I also wonder if she had been open about it would she have been able to get support and help from other staff working with this population. We have supervision meetings twice a week and the staff is very supportive in discussing "triggering" events and counter transference issues. I mentioned earlier that there was one other staff who had a personal history of an eating disorder as well as another diagnosis. She did not work out at Monte Nido due to her relapse into her other diagnosis which led her to poor boundaries with patients and continued violations of staff policies. Considering that Monte Nido has been in existence for five years and I have consistently maintained a staff where at least twenty-two or more are recovered from an eating disorder, we have a remarkable record.
Counter transference vulnerabilities
In addition to the increased risk of relapse, there are a variety of counter transference issues that staff with eating disorder histories can be more vulnerable to. If staff has recovered vis-a-vis a particular treatment strategy, they can err in the direction of becoming quite narrow and inflexible in their beliefs about how recovery occurs. Interestingly, the passion they feel for a technique, philosophy, or strategy is simultaneously their greatest strength and their greatest weakness. Clearly, there are times when our patients need straightforward, direct recommendations about how to recover. Sometimes, however, the reason the patient has the illness is because they need to explore what the right path of recovery needs to be for them. Staff members who have been there and done that can sometimes have difficulty allowing the patient to flounder around a bit as they search for their path of recovery.
Sense of mission
Staff members who have had good, powerful, healing experiences with therapists, sponsors, etc can feel substantial pressure to help others as they have been helped. These are extraordinarily dedicated staff that will always go above and beyond the call of duty to help patients. Unwittingly, their dedication can slip into a situation where the therapist is shouldering more responsibility for recovery than the patient. One would never want to dilute this type of staff's commitment to helping people recover. The art is to help them make sure that they do not take over the recovery process for the patient.
Both the Academy for Eating Disorders and the International Association of Eating Disorder Professionals need to create guidelines so that professionals who have personal recovery can have benchmarks to evaluate their readiness to enter the field. The criteria need to be as specific and concrete as possible. We recommend that the two organizations work collaboratively so as to avoid confusion regarding criteria. Overall, the organizations need to acknowledge the useful contributions these clinicians can make to the field. Our hope is that by openly embracing this group we can focus our energies on how to maximize their strengths and minimize their vulnerabilities.
Johnson, C.L. (1999). Been there - Done that: The Use of Clinicians with Personal Recovery in the Treatment of Eating Disorders. Presented at the Annual Meeting of the Academy of Eating Disorders, San Diego, CA
Bloomgarden, A. (2000) Therapist's Self Disclosure and Genuine Caring: Where do they Belong in the Therapeutic Relationship? Eating Disorders The Journal of Treatment and Prevention. Volume 8.Number 4 , 347-352
Bloomgarden, A., Gerstein, F., and Moss, C. (1999). Our Patients-Ourselves: Eating Disorder History Among Staff in an Eating Disorder Treatment Facility. Personal Communication
Strober, M., Freeman, R., and Morrell,W. (1997). The Long Term Course of Severe Anorexia Nervosa in Adolescents: Survival Analysis of Recovery, Relapse, and Outcome Predictors over 10-15 Years in a Prospective Study. International Journal of Eating Disorders, 339-360
Johnson, C.L. and Connors, M. (1997). Symptom Management of Bulimia. Journal of Consulting and Clinical Psychology. Vol. 55, 5, 668-676