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Eating Disorder Therapists’ Personal Eating Disorder History and Professional Ethics: An Interpretive Description Meris Williams & Beth E. Haverkamp To cite this article: Meris Williams & Beth E. Haverkamp (2015) Eating Disorder Therapists’ Personal Eating Disorder History and Professional Ethics: An Interpretive Description, Eating Disorders, 23:5, 393-410, DOI: 10.1080/10640266.2015.1013393 To link to this article:

Published online: 26 Feb 2015.

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Date: 24 October 2015, At: 14:57

Eating Disorders, 23:393–410, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2015.1013393

Eating Disorder Therapists’ Personal Eating Disorder History and Professional Ethics: An Interpretive Description MERIS WILLIAMS and BETH E. HAVERKAMP Downloaded by [University of Otago] at 14:57 24 October 2015

Department of Educational and Counseling Psychology and Special Education, University of British Columbia, Vancouver, British Columbia, Canada

This qualitative study sought to explore and understand eating disorder (ED) therapists’ perceptions of whether and how their personal ED histories had professional ethical relevance. Analysis of multiple interviews with 11 therapist-participants indicated that they perceived their personal ED histories as having substantial ethical relevance in their day-to-day practice with ED clients. The major categories of ethics experiences that emerged were: boundaries, therapist wellness, helpfulness of personal ED history, and openness regarding therapists’ personal ED histories. The findings have practical utility for the education, training, and continuing education of ED-historied practitioners.

The lifetime prevalence of eating disorders (EDs) among ED treatment professionals has been estimated as between 20% and 33% (e.g., Barbarich, 2002; Warren, Crowley, Olivardia, & Schoen, 2009). Questions have been raised about the potential benefits and risks associated with having EDhistoried practitioners deliver ED treatment (e.g., Bloomgarden, Gerstein, & Moss, 2003; Johnson, 2000; Johnson, Smethurst, & Gowers, 2005), invoking the professional ethical principles of beneficence (do good) and nonmaleficence (do no harm) (Beauchamp & Childress, 1994). Certainly, the ethics codes governing psychotherapy contain specific standards requiring practitioners to take responsibility for evaluating and addressing any personal mental health issues influencing the quality and safety of their work

Meris Williams is now in private practice. Address correspondence to Meris Williams, #335-2184 West Broadway, Vancouver, BC V6K 2E1, Canada. E-mail: [email protected] 393

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(e.g., American Psychological Association, 2010; Canadian Psychological Association, 2000). Suggested potential benefits of involving ED-historied practitioners in ED treatment have included the therapist’s enhanced therapeutic skills and sensitivities, including a high degree of empathy, deep understanding, and acceptance regarding clients’ ED experiences (e.g., Johnson et al., 2005; Warren, Schafer, Crowley, & Olivardia, 2013), which may be advantageous in forming and strengthening the therapy relationship. Furthermore, recovered ED-historied therapists may represent hope to clients with EDs (e.g., Costin & Grabb, 2012), which could bolster expectancy effects on therapy outcome. Potential risks identified have included that therapy delivered by ED-historied therapists may not provide maximal benefit to ED clients (or, more worrisome, that harm may occur) if ED-historied clinicians demonstrate lingering unhealthy thoughts, beliefs, attitudes, and behaviors related to eating, body weight, and shape (e.g., Johnson et al., 2005; O’Dea, 2000; Rutz, 1993). Moreover, the often lengthy duration of recovery from an ED in conjunction with the typical age of onset in adolescence to young adulthood implies that an ED may not be completely (or, in some cases, even remotely) resolved by the time an individual enters a career as a therapist. These concerns have prompted calls for guidelines to help entry-level practitioners with personal ED histories evaluate their readiness and suitability to work in the field (Bloomgarden et al., 2003; Johnson, 2000). The phenomenon of the mental health professional with a personal mental health history is not unique to the ED field: there has been wide documentation that practitioners experience a variety of mental health concerns that can impact their professional functioning (e.g., Bike, Norcross, & Schatz, 2009; Gilroy, Carroll, & Murra, 2001), and that may not be recognized as influencing their service delivery (Gilroy, Murra, & Carroll, 2002). However, the therapist-ED-client intersection presents a particularly compelling exemplar due to the high mortality rates, chronicity, and ambivalence about recovery seen in EDs. To date, scant research has been published on the topic of the ED-historied clinician (e.g., Bowlby, Anderson, Hall, & Willingham, 2015; Johnson et al., 2005; Rance, Moller, & Douglas, 2010), although the subject appears to be entering mainstream discourse in the ED field (e.g., the Academy for Eating Disorders [AED] Special Interest Group on “Professionals and Recovery”). Encouragingly, a recent study by Warren and colleagues (2013) explored whether and how clinicians perceived their personal ED history as having positive and/or negative influence on their treatment provision to ED clients. However, investigations framing these influences specifically as a professional ethical issue have yet to emerge. Given calls to explore the phenomenon of the ED-historied practitioner more fully, the directives in the ethics codes regarding clinicians’ personal mental health experiences, and ethical considerations of benefiting

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and avoiding harm to ED clients, exploratory research regarding the professional ethical implications of ED-historied therapists’ personal ED histories was warranted. This article reports selected results from a large-scale, qualitative investigation on ED therapists’ perceptions of whether and how their personal ED histories have professional ethical relevance. The study aimed to produce knowledge with practical utility for the education, training, and supervision of ED-historied practitioners.


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Approach to Inquiry Emerging relatively recently in qualitative health research, Interpretive Description (ID; e.g., Thorne, 2008) produces findings relevant to clinical practice and includes multiple safeguards to ensure trustworthiness and credibility. ID is undergirded philosophically by the constructivist-interpretivist paradigm, drawing strongly on naturalistic inquiry (Lincoln & Guba, 1985) and pragmatism (e.g., Patton, 1990).

Participants Participants were 11 female ED therapists ranging in age from 28 to 61 years (M = 43.36; SD = 10.29; Mdn = 44). The number of years providing therapy to ED clients ranged from 2.5 to 22 (M = 11.95; SD = 7.02; Mdn = 10.75). Highest degrees obtained were either Master’s (n = 6) or Doctorate (n = 5) in social work, marriage and family therapy, counseling psychology, clinical psychology, school psychology, or educational psychology. All participants self-identified as having historically experienced an ED of diagnosable severity. Participants reported experiencing anorexia nervosa (AN; restricting or binge-purge type), bulimia nervosa (BN; purging or nonpurging type), and/or eating disorder not otherwise specified (EDNOS). The duration of EDs ranged from 2 to 28 years (M = 11.77; SD = 8.42; Mdn = 10), with some framing this as approximate, due to their perception that recovery was gradual. Participants reported having received treatment for their ED in specialized ED treatment settings, non-specialized settings (e.g., seeing a generalist therapist), or having received no ED treatment at all. Participants reported having been recovered for between 3 and 29 years (M = 16.45; SD = 7.53; Mdn = 19). All reported that they were not currently experiencing a diagnosable ED. Participants’ work contexts included private practice, community health clinic, hospital-based ED program, outpatient ED program, college setting, residential ED treatment centre, and mental health center, and ranged geographically from rural (i.e., population of approximately 20,000) to very large urban (i.e., population of over 3,500,000) settings along North America’s


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west coast. Participants’ theoretical orientations included eclectic, cognitive behavioural therapy, psychodynamic, and humanistic. They reported a range of ethics training, ranging from none (other than studying for licensing exams) to one or more graduate level ethics courses and/or seminars, with the younger participants reporting more comprehensive and dedicated training in ethics.

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Researcher Constructivist-interpretivist qualitative research requires researchers to locate themselves so that the significant influences shaping the study are made transparent (Morrow, 2005). Principle ethics (e.g., Kitchener, 2000) and postmodern ethics (e.g., Prilleltensky, Rossiter, & Walsh-Bowers, 1996; Rossiter, Prilleltensky, & Walsh-Bowers, 2000) were the primary theories informing the first author. Principle ethics foregrounds the individual professional’s responsibilities. In contrast, postmodern ethics asserts that ethics are socially embedded and constructed, and that organizations have an ethical responsibility to foster unconstrained ethics dialogue, since power relations may affect how professionals perceive and address ethical issues (Prilleltensky, Rossiter, & Walsh-Bowers, 1996). The research topic was selected as result of the first author’s longstanding research and clinical interests in EDs, the therapeutic relationship, and professional ethics. The first author (M.W.) also personally experienced an ED, which resolved approximately 20 years ago. Throughout her supervised training in ED treatment, she had been interested in whether and how her ED history might impact my work with ED clients. Influenced by her ethics training, she neither assumed the involvement of ED-historied therapists in ED treatment as wholly beneficial or harmful, nor did she seek to legitimize (or de-legitimize) her work in the field. Rather, she imagined there might be potentially helpful, unhelpful, and/or harmful aspects to the phenomenon.

Procedure and Data Sources Recruitment. Inclusion criteria were that participants had provided counselling or therapy to ED clients for at least 2 years, and were providing these services at the time of recruitment; carried a proportion of at least onequarter ED clients in their caseloads; possessed at least a Master’s degree and were members of a professional organization with a code of ethics; selfidentified as having experienced an ED of diagnosable severity; were at least 22 years of age; and spoke English. Exclusion criteria included not meeting the inclusion criteria; self-identifying as having historically experienced ED symptoms that did not meet diagnostic criteria; and, when asked directly during initial recruitment contact, reporting a current ED of diagnosable severity.

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Due to logistical constraints, the participants totaled 11 (considered acceptable for an ID study). Participants were recruited via advertisements distributed through electronic mailing lists to relevant professional organizations. Hardcopy flyers were mailed to ED treatment programs in one Canadian province and two U.S. states. During data collection, one therapist from a rural community was added to enhance variation regarding community size and recency of personal ED history. All were provided one $20.00 bookstore gift card. Informed consent was obtained with participants prior to commencing the first interview. Consent and the right to withdraw from the study were reviewed at the beginning of each subsequent interview. Despite efforts to maximize variation, an all-female group of limited ethnic heritage was ultimately recruited. Interview procedure. Each participant was interviewed three times. The first two encounters were in-person interviews at participants’ workplaces (90 minutes), and the third interview (20–30 minutes) was conducted by phone. In the second and third interviews, emerging patterns in the data were discussed, previous interview material was clarified, new questions relevant to the investigation were posed, and the degree to which researcher initial understandings and interpretations of participants’ experiences reflected their meanings was explored (Morrow, 2005). Interviews were audio-recorded and transcribed by an independent transcriber who had signed a confidentiality agreement. The first round of interviews employed a simple, semi-structured protocol that supported the exploratory aim of the research, such that the participants had wide leeway to identify and discuss what they construed as their ethics experiences. The first interview protocol contained two questions: “Can you tell me what interested you in my study?” and “Tell me about your experiences of professional ethics in working with eating disordered clients.” Demographic information was obtained in the initial portion of the first interview. At the beginning of each first interview, the interviewer (MW) made a brief self-disclosure statement acknowledging her personal ED history. In the second and third interviews, participants were asked about any reflections since the first interview, and were again posed the main interview question. Consistent with ID and constructivist-interpretivist research, additional questions were added to reflect emergent trends in the data and to facilitate further exploration. Ethical considerations. This study was approved by the University of British Columbia’s Behavioral Research Ethics Board (#H09-02828). Standards in the Canadian Code of Ethics for Psychologists (CPA, 2000) pertaining to the conduct of research were adhered to throughout the study. All participants were provided a list of local counseling resources in the event that the interviews prompted thoughts, feelings, or behaviors that required support. The fluid, exploratory, interpretive, and emergent nature of ID necessitated that ethical issues be considered throughout the duration of the study


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(e.g., Haverkamp, 2005). Researcher reflexive journaling about ethical concerns was ongoing, and any ethical issues were discussed with the research supervisor whose scholarly focus is professional ethics.

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Data Analysis and Trustworthiness Analysis was inductive and maintained a holistic, contextualized perspective of the data (e.g., broad, analytic questions were employed, such as “Why is this here?”, “Why not something else?”, “What does it mean?” [Thorne, 2008]). Data analysis transitioned from description to interpretation, such that thematic findings moved beyond self-evident, initial descriptive claims towards more abstracted interpretations identifying the potential meanings of the results. Emergent themes and patterns were discussed regularly with supervisors and other researchers. ID quality/trustworthiness criteria included epistemological integrity, pragmatic obligation, and the thoughtful clinician test (Thorne, 2008). Criteria for constructivist qualitative research as listed in Morrow (2005) were also employed. A comprehensive description of how trustworthiness criteria were applied in the present study can be obtained from the authors.

RESULTS: ETHICS EXPERIENCES ASSOCIATED WITH PERSONAL ED HISTORY Reported here are results emerging from the manifest content analysis of the interview data, comprised of participants’ descriptions of their ethics experiences in their day-to-day work with ED clients that they linked explicitly to their personal ED histories. Four categories emerged: (a) boundary issues, (b) therapist wellness, (c) helpfulness of the therapist’s ED, and (d) openness regarding therapists’ personal ED histories. Each of these contained sub-categories of ethics experiences or other significant conceptual elements. As per constructivist-interpretivist qualitative research reporting, participant quotations are included for illustrative purposes.

Boundary Issues Boundaries were perceived by participants to function as a means of safeguarding and serving the client regarding shared ED history. Three subcategories were: (a) centralizing the client’s ED experience; (b) self-disclosing ED history; and (c) dual relationships. Centralizing the client’s ED experience. All interviewees stated close variants of the statements “everybody’s ED experience is different” and therapy being “about the client, not about me.” They considered self-knowledge of one’s personal ED history to be necessary for addressing any false

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assumptions of similarity with one’s ED clients. Participants’ ethical rationales included minimizing potential harms arising from misunderstanding or misinterpreting clients’ experiences, and concern about the content and direction of therapy being based inappropriately on the therapist’s ED experience. For example, one therapist stated:

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An ethical issue is knowing myself enough to know that my [ED] experience isn’t the only one, and that I can’t guide my practice based on what worked for me personally. (P10-2, 281–283)

Participants reported that “overly relating” to clients’ ED issues could invite unhelpful or harmful boundary crossings. Meeting one’s own needs in therapy by bringing in and/or attempting to deal with personal, unresolved ED-related issues (including those outside of one’s awareness) were viewed as the therapist unhelpfully centralizing herself. Some noted that, while a therapist’s ED history could not be undone, ethically it needed to be “bracketed” so as to continuously centralize the client, thus staying true to the purpose of therapy. Self-disclosing ED history. Participants reported disclosing their personal ED histories to differing degrees, from marketing oneself as a recovered therapist, to infrequent disclosure, to non-disclosure. Some disclosed their ED histories to clients without being asked, while the others did so only if asked directly by a client, “Have you had an ED?” Both groups rationalized their respective stances on the ethical basis of offering benefit to clients. For example, waiting to be asked was proposed to helpfully maintain the focus of therapy on the client’s issues and journey. Conversely, volunteering this information was thought to benefit clients through modeling non-shame and inviting further disclosure. Ethical concerns identified by participants regarding self-disclosing personal ED history included inadequate guidance and/or preparation regarding its use, and the ethics codes’ lack of explicit directives. Some participants described having had few opportunities to ethically consider how to respond to clients’ questions about their ED histories. There was also concern that disclosing personal ED history could unhelpfully or harmfully contribute to side-stepping or curtailing exploration of the client’s experiences (“I like to work on shame . . . without saying, ‘Me too. Now we should feel better’” (P11-2, 220–223). Errors in self-disclosing personal ED history were reported to have occurred mainly in early career or early recovery. For example, one participant recalled an early career decision to disclose her lowest weight when asked to by a client: [The client] thought that if I could get that low and come back, then she had a ways to go before she had to worry about it. . . . [It was] awful. Awful. Scary. I don’t discuss those details anymore. (P5-1, 328–332, 334–340)

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Regarding broader ethical issues, one participant reported the experience of ED program clients coming to believe that the self-disclosing ED-historied therapists understood them better than the non-ED-historied therapists. Consequently, she said, clients underutilized the services of the equally qualified (but non-ED-historied) practitioners, resulting in a negative workplace climate and less effective teamwork, thus potentially reducing benefit to clients. Dual relationships. Two participants identified 12-Step models as helpful for maintaining their personal ED recoveries, and were faced with considering dual relationships when encountering their clients at 12-Step meetings. One worked in a very small community, and chose to attend meetings even though her clients could be in attendance. The other, from a large city, attended meetings initially, but found alternative supports when she encountered clients there.

Therapist Wellness In this second major category of ethics experience, the definition of therapist wellness that emerged encompassed therapists’ perceived degree of resolution and health regarding their personal ED, and their accurate selfevaluation of these. Therapist wellness appeared to hold a central position among the other major categories. For example, it was thought to influence the degree to which therapy boundaries could be navigated beneficially and safely with ED clients. It was also perceived to influence the degree to which a therapist’s ED history could actually be helpful to clients (e.g., in modeling genuine recovery). Although they did not define “recovery,” participants considered insufficient therapist wellness to be ethically problematic due to the potential for increased risk of harm to clients (e.g., therapists’ unresolved ED issues adding to their clients’ already significant burdens) and decreased helpfulness (e.g., sending conflicting messages that could hinder client recovery). Described below, sub-categories of therapist wellness were: (a) experiencing an active ED; (b) experiencing “residual” symptoms; (c) integrating one’s personal ED experience in a healthy way into one’s identity and work with ED clients; (d) being congruent; (e) having self-awareness/blind spots; and (f) being “real.” Experiencing an active ED. Two participants reported having provided services to ED clients while personally experiencing an ED of diagnosable severity. One participant described realizing, only in hindsight, that she had experienced a resurgence in ED symptoms when shifting from providing generalist, non-ED therapy to working with ED clients. She stated: [It] triggered the anorexic side. . . . Every time I’d go to the doctor, they would put “anorexic,” and it was just driving me nuts because I didn’t think I was anorexic . . . [but] I was underweight. (P3-1, 193–196)

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The other participant, who had practiced while symptomatic with bulimia, stated that, for her, wellness was about moving towards “wholeness,” which she believed was facilitated by continuing to acknowledge and address her ongoing vulnerabilities regarding her ED history. Experiencing ED residuals. The concept of “residuals” as an ethics experience was defined by participants as the presence of un- or under-resolved aspects of the therapist’s ED history that, while not indicative of a full-blown ED, nonetheless suggested something less than full wellness or resolution. Sub-types of residuals were: (a) “sticky bits” (i.e., unexpected, fleeting encounters with vestiges or reminders of one’s personal ED in the form of thoughts, feelings, and behaviors); (b) continued body, weight, and/or eating concerns, which participants noted could send inappropriate mixed messages to clients; (c) continued high expectations, “pushing” of self and others, and perfectionism, which were conjectured by participants to impede the therapist’s performance and impose unrealistic expectations onto clients; (d) challenges in “keeping on top of” aspects of the work, such as being organized, and being able to sit with, track, and process clients’ emotions, and (e) under-reacting to client risk/safety. Regarding this last sub-category, one participant said, “I don’t feel especially proud of this” (P8-3, 134), reporting that, as a trainee, she had not recommended more intensive treatment to a very ill AN client. The participant attributed this to her own experience of having been a “high functioning,” severe ED sufferer. Fortunately, this “near miss” was addressed in supervision. Ethically, participants said, therapists’ ED residuals require adequate resolution in order to provide the safest and most effective care to ED clients. However, they also noted it was not always straightforward to ascertain whether the degree to which they experienced certain phenomena (e.g., body image distress, “picky eating”) was culturally normative for women, versus an un- or under-resolved aspect of their ED. Integrating the ED. Participants’ ethics experiences regarding “integrating” their EDs had two emergent components: (a) the healthy (versus ego-syntonic) incorporation of the therapist’s personal ED experience into her sense of self; and, subsequently, (b) the appropriate incorporation of the therapist’s ED history into her work with ED clients. They described the benefits to clients of integration as including enhanced relational connection and modeling health. Participants perceived a lack of integration regarding ED history as potentially leading to the unacknowledged, avoided, or “split off” part(s) of that history entering unmindfully into therapy in potentially harmful or otherwise problematic ways (e.g., hindering relational connections, or inappropriately modeling ED characteristics). Speculating that un-integrated aspects of her ED history might persist and negatively impact her ability to connect with some of her ED clients, one participant reported considering personal therapy for “knitting together” and “bringing forward” these parts of herself. She stated: “[I]t’s hard to do the work without integrating these pieces I feel are unfinished” (P4-3, 85–86).

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Having self-awareness, blind spots. Self-awareness was mentioned spontaneously and adamantly by several interviewees as being critical to their ethical practice with ED clients. The definition that emerged was the degree to which participants possessed self-knowledge regarding various aspects of their ED histories, and whether they could accurately self-evaluate their degree of recovery/wellness. Therapist self-awareness was perceived by participants to evolve over time, with maturation as a person and professional, and via training and supervision. Various participant statements suggested that therapists with more recent ED experiences were more likely to be experiencing an intensive period of developing self-awareness about their ED histories. For example, a participant who reported beginning her recovery journey within the last 3 years had noted a rapid and profound surge of self-awareness. Another remarked: “[W]hen I was a younger therapist, I would probably deny I had blind spots” (P2-3, 101–102). Blind spots were described as ethically problematic, since unexamined material could more easily enter therapy in unhelpful or harmful ways. Noting that she had historically used her personal ED history to inform treatment decisions for clients, a participant stated: Our stuff can become predatory if it’s not dealt with. . . . It slips out. It’s leaking out . . . I think the ethical part is: you better know how your [ED] story impacts the way you see other people. (P10-1, 1610–1616; P10-2, 486–487)

Participants asserted that engaging in self-reflective dialogue with trusted others (e.g., through formal supervision, team meetings, and personal therapy) was crucial in developing self-awareness and identifying blind spots regarding personal ED history. However, participants also described having their blind spots revealed to them unexpectedly. One participant said: I [gave] a talk . . . on EDs and this . . . audience [member] says, “Well, you’re still eating disordered,” and I said, “No, I’m not.” [She replied,] “Well, just look at you.” . . . I was restricting and I didn’t feel like I was. (P3-1, 196–203, 227)

Participants also reported observing fellow therapists’ blind spots, suspecting that some had not resolved their ED sufficiently enough to provide effective care to ED clients. For example, a participant who had overseen a hiring process said: In people’s heart of hearts, they think they’re well. . . . [T]here’s . . . a grey area where people are not as responsive to [their] ED . . . and think they’re beyond it, but maybe, objectively, aren’t. (P9-3, 174–180)

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Being congruent. Participants reported that offering maximal benefit to ED clients included demonstrating congruence between helping clients overcome problems with food, eating, exercise, and body acceptance, and maintaining personal awareness and health in these areas. As one participant stated:

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[W]orking with clients with EDs keeps me honest. I really don’t like the idea of giving a piece of advice and then going out and doing the opposite. (P5-2, 544–547)

Being real. While some participants linked being real (i.e., defined by interviewees as being authentic, genuine, and truthful when interacting with ED clients) to disclosing aspects of their personal ED history to clients, others defined it as refraining from portraying oneself as an expert or seeing clients as “other,” and extending courtesy and respect to clients due to one’s personal ED experience. Ethically, participants said, being real could benefit ED clients and the therapy process through demonstrating trustworthiness, honesty, and respect. They asserted that such expressions of realness necessitated appropriate boundaries.

Helpfulness of the Therapist’s ED In this third major category of ethics experience, participants conveyed their perception that their personal ED histories helped their work. Three sub-types of helpfulness emerged: (a) “getting” clients’ ED experiences; (b) instilling and maintaining hope; and (c) sensitivity, respect, and compassion. “Getting” clients’ experiences. Participants viewed their ability to deeply “get” their ED clients’ experiences as ethically relevant in terms of benefiting clients through an enhanced therapeutic relationship characterized by connection, therapist credibility and trustworthiness, diminished power imbalances, anticipation of clients’ directions in therapy, and empathy. Participants reported instances of clients telling them that they had liked, appreciated, or found the therapist’s ED history comforting because they had felt understood. As one participant said: There’s a particular way [ED clients] think that’s especially understandable if you’ve been through it. . . . [Clients say] “I’m glad to know that you’ve been through this before. I know you’ll understand.” (P5-1, 303–306, 316–317)

Instilling and maintaining hope. Instilling hope was linked by some participants to the idea of ED-historied therapists serving as positive role models for achieving recovery, which was considered an important benefit that therapists could offer. Participants also asserted that their personal ED


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histories enabled them to maintain hope for their clients’ recovery when clients felt scant hope for themselves, and to buffer feelings of frustration and hopelessness about clients’ recovery trajectories. A participant stated: There were many years where I didn’t think I would ever recover. So, knowing that it’s possible helps me to encourage them to believe that. (P8-2, 818–819)

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Having sensitivity, respect, and compassion. Participants reported their ED experiences had fostered in them a strong commitment to treat ED clients with sensitivity, respect, and compassion, and “not practicing in an us/them kind of perspective, or seeing . . . [clients] as being those people over there with problems” (P1-2, 298–302).

Openness In this final major category of ethics experiences, openness was identified by participants as the degree to which they were open about their personal ED histories in work-related contexts, but also included their perceptions of the degree of openness of workplaces and/or the broader ED field to the presence of ED-historied therapists. Together, these influenced the degree to which participants felt they could be genuinely themselves at work; participated in on-site supervision/consultation about ethical issues relevant to their ED histories; and perceived consultation/supervision as effective, and therefore engaged in them fully. Some interviewees described working in settings in which they perceived therapist ED histories were accepted, and, in some cases, considered an asset to the work. These participants tended to have disclosed their ED histories at work, and reported more positive experiences of interacting with colleagues about ethical issues associated with practitioner ED history. However, even in more open workplaces, challenges were experienced by some participants (e.g., degree of wellness, based on body shape, being openly distrusted by other staff). Two participants reported examples of extremely distressing interpersonal interactions at work regarding their ED histories. One described working with a colleague who had openly and repeatedly expressed negative attitudes about ED-historied clinicians towards team members known to have personal ED histories. She noted that, as a result, team consultation had become “far less collaborative and trusting” (P1-1, 604, 616–617) as well as shorter in duration, which she perceived could have negatively impacted client care. Another participant described a situation in which she had been approached by a colleague about a noticeable weight loss (characterized by the interviewee as resulting from high stress versus the re-emergence of her ED), and had felt open to hearing this individual’s concern and feedback. She reported:

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[I said to the individual:]“Yeah, it’s something I’m aware of and I’m working on,” and, “No, it’s not affecting my work and, no, there’s no ED, and I know the difference.” . . . And so, [they’re] like, “Don’t tell anyone else that.” . . . I was so angry. . . . It felt very invalidating. . . . It’s like, “Did you come to talk to me because you think it’s something that needs to be hidden?” (P7-1, 688–690, 700–707, 717–718)

Both these participants described feeling observed or “watched” by others at the workplace regarding their appearance and behaviors. One felt monitored in a more negative sense. The other stated that being told she was “looking better” by her colleague made her feel somewhat relieved that her weight was likely no longer being scrutinized. Other participants worried about being judged negatively by colleagues regarding their ED histories if these were to become known, that they didn’t want to be thought of as having an unresolved ED, and that talk of unrecovered practitioners in the field was “whispered in the corners” (P6-1, 1151). Workplace norms of non-disclosure regarding professionals’ personal ED histories were perceived by some participants as contributing to interpersonal interactions that rendered team consultations unsafe, and inhibiting discussions they might have found effective in helping them grow ethically as an ED-historied therapist. One participant noted that, consequently: “I go to work and I do the work, but, in some ways, this part of me [the ED history] is cut off” (P4-3, 234–235). Non-acknowledgment and/or nonacceptance within workplaces regarding the presence of practitioners with personal ED histories (and any unique vulnerabilities or ethical issues they might encounter) was also identified as being ethically problematic in and of itself. One participant queried: “How can [we] not be triggered in this work? . . . To be in a context that does not accept that, I think, is unethical” (P10-1, 1639–1641). Furthermore, such atmospheres were perceived as having the potential to negatively impact client care in terms of perpetuating messages that EDs are shameful and should be kept to oneself, and increasing the risk of therapists’ unresolved ED issues impacting clients adversely. A participant commented: [H]alf the people I know in this field have personal histories . . . and it’s neglected, it’s avoided, it’s stigmatized—even within our own field as we’re trying to counter that stigma in the world and with our patients who are living with that. [That’s] a dissonance I don’t like to sit with. (P7-1, 312–317)

Some participants maintained relationships (sometimes over great geographical distances and several years) with trusted off-site supervisors, consultants, and/or mentors who knew about their ED histories, and with whom they felt safe to talk about “everything” that could come up regarding those histories.


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Regarding openness in the broader ED field, one participant stated that it was “not the safest or the most comfortable field to work in” (P1-1, 940) due to perceived negative attitudes about ED-historied practitioners involvement in ED treatment. Another said:

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There’s a lot of misconceptions about therapists that have personal histories and how that influences their work. . . . It is taboo. When you go to an ED conference . . . and talk to other trainees when so many of them [have ED histories], it’s like this secret conversation that we’ll have. . . . [It] feels hypocritical. (P7-1, 342–343, 426–431)

Ethically, this broader context was viewed by participants as having the potential to foster therapist isolation, leading to insufficient or inadequate consultation and supervision. It was also perceived as hampering the development of therapist self-awareness due to scant opportunities for dialogue around how others attend to these issues.

DISCUSSION The results of the study indicate that participants viewed their personal ED histories as having substantial ethical relevance in their day-to-day practice with ED clients: boundary issues, therapist wellness, perceived helpfulness of the therapist’s personal ED, and openness regarding therapists’ personal ED histories all emerged as categories of ethics experiences specific to those histories. The findings offer an initial glimpse into the types of ethical issues/concerns such clinicians may encounter when working with ED clients, as well as clues to how such practitioners might be best ethically supported. The findings are consistent with, and expand upon, previous investigations describing similar themes; however, the present results reveal these issues as explicitly having professional ethical relevance. Particularly noteworthy are results suggesting there may be a period of unique professional ethical vulnerability for ED-historied therapists when in early career and/or early recovery, specifically in the areas of (a) therapist wellness and (b) boundary issues. This lends credence to scholarship calling for guidelines to help entry-level practitioners with personal ED histories evaluate their readiness and suitability to work in the field (e.g., Bloomgarden et al., 2003; Johnson, 2000). Participants in this study reported that their ED histories had entered therapy in unexamined ways during these times, which they perceived had led to ethical challenges and errors associated with potential increased risk of harm to clients. Regarding early career/early in recovery therapist wellness, participants reported experiences such as having been symptomatic and unaware of it, self-absorption in one’s personal recovery, and using one’s personal history to guide treatment

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decisions for clients. Self-disclosure of personal ED history seemed to represent an area of high ethical awareness, high ethical uncertainty, and high ethical concern for participants. Early career and/or early recovery difficulties included not knowing how to respond to client requests for information about the therapist’s personal ED history, and a lack of foresight regarding the potential impacts on clients of certain disclosures. In this study, two participants recounted early career/early in recovery missteps that provide compelling evidence of the potential dangers of unexamined aspects of the therapist’s personal ED history entering into therapy with ED clients (i.e., inadequate referral; potentially harmful self-disclosure). Such errors suggest strongly that ED therapists with personal ED histories may require early support and guidance in identifying and navigating these ethical pitfalls, particularly in the form of supervision. Also noteworthy were findings regarding lack of perceived interpersonal safety in some sectors of the ED field for ED-historied practitioners, and the importance of dialogue with trusted others for developing selfawareness around how one’s personal ED history enters into therapy, identifying blind spots, and/or consulting around associated clinical and ethical issues. Participants reflected that lack of such dialogue could foster therapist isolation, discourage consultation and supervision, and inhibit development of self-awareness and integration regarding personal ED history, thus potentially allowing the therapist’s unexamined ED issues to enter into therapy with ED clients in unhelpful or harmful ways. Therefore, developing safe climates to permit such dialogue seems ethically prudent. This is consistent with a positive ethics approach, which promotes consideration of ethics within an atmosphere of openness rather than fearfulness, as well as within broader contexts, including personal and professional values and aspirations, and social influences (Handelsman, Knapp, & Gottlieb, 2009). Future research should continue to address professional ethics and the ED-historied practitioner, including ascertaining whether the categories in the present study are generalizable to the population of ED-historied therapists; developing decision models to assist in ethical reasoning about self-disclosure of personal ED history; operationalizing the concept of safe climates for ethics dialogue relevant to ED-historied therapists; and investigating others’ (e.g., supervisors’, clients’) perceptions of the ethical relevance of therapists’ personal ED histories. Consistent with the constructivist-interpretivist paradigm of science, the rigor of this study is judged on criteria such as breadth and depth of understanding (Thorne, 2008; Morrow, 2005). Therefore, its limitations include: (a) reliance on interviews as the sole data source; (b) no interviewees were included who were not able to use a professional ethical lens to discuss the research topic, or who were so uncomfortable with the topic they could not discuss it with a researcher; (c) limited variation in participant gender and


M. Williams and B. E. Haverkamp

ethnic heritage; and (d) limited understanding of the ethics experiences of “true beginner” therapists due to the inclusion criterion stipulating at least 2 years of experience working in EDs.

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CONCLUSIONS The findings of this discovery-oriented investigation contribute to our understanding of the ED-historied clinician by offering a rich and holistic interpretive-descriptive account of how one group of ED therapists with personal ED histories perceived those histories as professionally ethically relevant. Furthermore, by situating the topic as explicitly ethical, a more nuanced understanding of the potential benefits and risks regarding the involvement in ED treatment of these clinicians was generated that goes beyond “pros and cons” or “positives and negatives.” The findings are of practical utility for ED-historied therapists, as well as for the individuals who educate, train, and supervise them.

ACKNOWLEDGMENTS This article is based on Meris Williams’s PhD dissertation research conducted under the supervision of Beth E. Haverkamp at the University of British Columbia. Portions of the study were presented as posters at the Renfrew Center Foundation Conference, Philadelphia, PA, in November 2012 and at the Canadian Psychological Association Conference, Vancouver, British Columbia, in June 2014.

FUNDING This research was supported in part by grants from the Social Sciences and Humanities Research Council of Canada and the Michael Smith Foundation for Health Research.

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Eating disorder therapists' personal eating disorder history and professional ethics: an interpretive description.

This qualitative study sought to explore and understand eating disorder (ED) therapists' perceptions of whether and how their personal ED histories ha...
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