Male clinicians experiences of working with patients with eating disorders: An interpretative phenomenological analysis

David Viljoen Hertfordshire Community Eating Disorders Service, Hertfordshire Partnership NHS Foundation Trust, UK

Background
Just as one cannot not communicate, one also cannot not do gender. Knudsen-Martin (1997, p. 429)
Gender is a significant and subtle factor in therapy. Previous studies (e.g. Gehart & Lyle, 2001; Waller & Katzman, 1998) have explored aspects such as patientclinician gender matches, the effect of a clinician's gender on the therapeutic process and outcome, and the role of clinicians gender from the patient's perspective. However, despite the importance of the clinicians role in treatment research has largely ignored male clinicians views and experiences of working in the eating disorders field (Jarman et al., 1997). For example, clinicians constructions of gender and other personal and professional perspectives might inform their interactions with patients and dictate which themes they will explore or overlook in therapy. Consequently, rather than the usual research orientation towards patients, this ideographic pilot study endeavours to provide an overview of male clinicians subjective experiences of the relevance of their gender and the issues related to working with patients with eating disorders.

Results
Figure 1 illustrates the five superordinate and subordinate themes that emerged from the analysis. These themes captured the essence of the participants shared experiences of working with patients with eating disorders.

Conclusions
Broad generalisations should be avoided given the relative small sample size. However, this pilot study highlighted the importance of male clinicians gender as context for the treatment of patients with eating disorders. The study has several potential clinical and research implications: Self-reflexivity: Self-awareness regarding the personal and professional meanings that clinicians attach to topics such as gender, sexuality, food and weight are important and can enable clinicians to use their selves for the therapeutic benefit of their patients. Clinicians gendered use of self: The study discussed a variety of areas in which male clinicians can constructively use their gendered selves both in therapy and within the team context. Gender-sensitive therapy: Male clinicians struggle to move beyond gender stereotypes in their interactions with patients and colleagues. To prevent these roles from becoming restrictive clinicians and services should re-examine their beliefs/practices to ensure gendersensitive treatments for patients. Recommendations are made based on ideas from feminist models. Usefulness of qualitative methods: Qualitative methods have increasing value in clinically orientated research and to capture clinicians and patients subjective experiences. It is hoped that this pilot study will generate hypotheses for more extended research regarding the perspectives and experiences of clinicians and patients and how this might inform the development of gender-sensitive models of treatment for patients with eating disorders.

FIGURE 1: MALE CLINICIANS EXPERIENCES OF WORKING WITH PATIENTS WITH EATING DISORDERS

1. Use of self: Relevance and value of male clinicians gender in treatment

2. Significance of male clinicians gender in the treatment unit and team context
2.1 Balancing predominantly female treatment environments 2.2 Interplay between gender, profession and positions of authority 2.3 Stereotypical gender roles in which clinicians position themselves/are being positioned by colleagues

3. Complexity of the notion: Relevance of a male clinicians gender

4. Sexuality

5. Self-reflexivity: Personal meaning of food, weight and body image

1.1 Alternative experience to male figures in patients lives 1.2 Ways in which clinicians position themselves/are being positioned by patients 1.3 Working with male family members 1.4 Treating male patients 1.5 Taking up a political responsibility 1.6 Contributions in co-working 1.7 Patient-clinician gender matches

3.1 Divergent and contradictory views 3.2 Other variables too are important 3.3 Difficult to separate gender out 3.4 Interplay between gender and other variables 3.5 Relevance of gender is wider than the eating disorder context 3.6 Role of gender can be exaggerated

4.1 Increased sexuality with weight restoration and potential attractiveness to patients and staff 4.2 Self-reflexivity: Risk of male clinicians being attracted to patients 4.3 Safety and risk management 4.4 Sexuality discussed in varying degrees on units 4.5 Reasons for not discussing sexuality

5.1 Personal meaning of food, weight and body shape 5.2 Reasons for entering and staying in the field: Chance or a selection process? 5.3 Effect of work on personal meaning of food, weight and body shape 5.4 Use-of self: Implications for treatment

Methods
Five male clinicians in the UK (representing several professional disciplines and a mean of 12 years experience working with patients with eating disorders) were interviewed about their subjective experiences and understandings of the relevance of their gender and the issues related to the treatment of a primarily female patient group. Semi-structured interviews were used. The verbatim transcripts were qualitatively analysed using the principles of Interpretative Phenomenological Analysis, such as: seeking subjective "insider perspectives" of experiences rather than objective descriptions; using small numbers of participants because of the detailed case-by-case analysis; accepting the researchers role in knowledge production. The author worked systematically through the transcripts to identify themes and categories that were progressively integrated until higher-order themes were identified that represented the nature of male clinicians experiences. A cyclical process was employed at all stages and care was taken to ensure that all themes threaded back to the verbatim transcripts and reflected in detail the participants accounts.

1.8 Alternative contributions to female clinicians 1.9 (In) ability to understand womens obsessions with weight, body image and the cultural/media pressures

Male clinicians reported that their gender was relevant, significant and valuable in the treatment of patients (e.g. providing an alternative to the male figures in patients lives; working with male family members and male patients; taking up the political responsibility to challenge gender stereotypes/roles; when co-working with female colleagues; offering patient-clinician gender matches; using their [in]ability to understand womens obsessions with weight/body image and the cultural/media pressures). The presence of male clinicians has a gender balancing effect in primarily female teams and treatment units. Interviewees positioned themselves and were positioned by patients and female colleagues in gender stereotypical roles (e.g. father figure or problem solver) which could become restrictive at times. The notion of the relevance of a male clinicians gender in the treatment of patients with eating disorders is complex. Participants discussed their difficulty separating gender from other variables (e.g. age, skills and personality) as well as the importance of these respective variables and their interplay with gender. The relevance of a clinicians gender is wider than the eating-disorder field and there is also a potential risk of over-emphasising the importance of male clinicians gender. Participants reflected on the increased sexuality of patients with weight restoration which could lead to sexual attractiveness to other patients or staff. The potential issue of male clinicians being sexually attracted to patients and the importance of selfawareness, boundaries, safety and risk management was highlighted. For a variety of reasons, issues of sexuality was not discussed in treatment with patients or amongst clinicians in teams and more opportunities should be created in this regard. Clinicians reflected on a range of personal meanings related to food, weight and shape. For some these personal meanings might have contributed to entering and staying in the eating disorder field. Depending on their different understandings of the role of food in . eating disorders, clinicians had different views on how their work in the field has affected the meaning of and their relationship with food and their own weight and body image. While some clinicians self-reflexively used their personal relationship with food, weight and exercising in treatment, one clinician found these personal meanings less helpful in the treatment process.

References
Gehart, D.R. & Lyle, R.R. (2001). Patient experience of gender in therapeutic relationships: An interpretative ethnography. Family Process, 40, 443-458. Jarman, M., Smith, J.A. & Walsh, S. (1997). The psychological battle for control: A qualitative study of health-care professionals understandings of the treatment of anorexia nervosa. Journal of Community & Applied Social Psychology, 7, 137-152. Knudson-Martin, C. (1997). The politics of gender in family therapy. Journal of Marital and Family Therapy, 23, 421-438. Waller, G. & Katzman, M.A. (1998). Female or male clinicians for women with eating disorders? A pilot study of expert opinions. International Journal of Eating Disorders, 23, 117-123.

Acknowledgments
I would like to thank my family for their support and the Bedfordshire and Luton Partnership NHS Trust for part funding my Masters degree in Systemic Psychotherapy.

For further information

Address: Hertfordshire Community Eating Disorders Service, Centenary House, Hitchin, Hertfordshire, SG5 1JN, UK; david.viljoen@hertspartsft.nhs.uk