BRIDGEPOINT CENTER FOR EATING DISORDERS
EVALUATIVE INQUIRY:
LEARNING ABOUT EXPERIENCES, OUTCOMES AND PRACTICE

Prepared by:
Barbara Sykes and Lynda Workman,
Wolfe-Gordon Consulting
For:
BridgePoint Center for Eating Disorders
May 2002

EXECUTIVE SUMMARY
BridgePoint Center for Eating Disorders was established in Milden, Saskatchewan in 1995 to address a pressing need for intensive rehabilitation for individuals with eating disorders. From 1997 to 2000, BridgePoint was funded as a three-year demonstration project undertaken in collaboration with Saskatchewan Health and Midwest District Health. The BridgePoint board and team members initiated this evaluative inquiry in order to gain a deeper understanding of the impacts of the program for participants and family members and to articulate the practice that contributes to identified outcomes. They also sought to learn more about the meaning of recovery as it is experienced by people living with eating disorders.
The methodology used in this inquiry is grounded in the use of qualitative methods of data gathering, analysis, and interpretation. Data gathering was based on involvement of two evaluators in portions of two program modules and on interviews with current and former program participants, family members of participants, team and board members, and counselors based in the community. In all, 47 individuals were interviewed, individually or in small groups.

SUMMARY OF LEARNING FROM THE INQUIRY

Experiences of Participants

Participants offered important learning about the realities of living life with an eating disorder - about the difficulty of struggling day-to-day with the pain, secrecy, isolation, and shame that so often accompany an eating disorder. They talked about the extent to which their eating disorders had dominated their lives and left little room for "normal" relationships and activities. The decision to go to BridgePoint was most often made from a place of desperation, serious crisis or deep frustration.
Participants' stories of what it was like to be at BridgePoint and what made a difference to them personally were striking in the similarity among the themes that were reflected. These themes represent the important qualities of BridgePoint that contribute to outcomes and demonstrate the mindfulness and intentionality underlying the practice. Taken together, the voices of participants portray BridgePoint as "a safe and caring community in which we are accepted for who we are. We realize that we do have choices and we are held able for making decisions about our own lives. It is a place where we discover important elements of ourselves and learn to communicate authentically with others."

• Elements That Made a Difference

Safety: The experience of safety was profound for participants. They made it clear that safety was the context in which they felt able to move forward in sharing their stories, working through their issues and taking advantage of what BridgePoint has to offer.

Caring and Acceptance: Participants emphasized the extent to which they were offered unconditional love and acceptance. Meeting with such care and acceptance from team members and other participants was a powerful experience that opened the way for participants to feel more accepting of and compassionate toward themselves and others.

Community: The strong sense of community that participants identified was tied to the "normalcy" of life at BridgePoint: connecting with people – both team members and other participants - in ways that feel like family or community. Community was also experienced as being in it together, which was described as taking care of each other, hearing each other, and working toward the same ends.

Having Choices and Being Held Able: Participants emphasized the extent to which being made aware of choices and being held able to make good decisions was central in helping them move forward in the recovery process. Being held able allowed them to shift their understanding of choice and to take ownership of their own issues, behaviours, and decisions.

Authenticity – Being Real: The authenticity or "realness" with which team members engaged with participants enabled women to share their stories and offered hope for recovery. In particular, knowing that some team members had also had eating disorders and had successfully dealt with them was powerful in opening up possibilities of living life differently.

Process of Self-Discovery: Being at BridgePoint was described by some participants as a "life-changing" experience. In many cases, BridgePoint was the place where these women began to discover "who I really am". It was the place where they began a guided and supported process of self-discovery that would continue long after they had left BridgePoint.

Involvement of Family Members: For some participants, involvement of their parents, partner, or siblings in the program resulted in important changes in family dynamics and offered a more supportive context for their recovery process.

• Outcomes

All of the participants who shared their stories with us were able to name changes in themselves and their lives that they attributed to being involved with BridgePoint. Outcomes include:

Change in Eating Disorder Behaviours: For most participants, an important outcome was a change in eating disordered behaviours. While we hear in their accounts the extent to which many participants continue to struggle with their eating disorders, what stands out is the success that these women experienced in making different choices and changing established patterns of behaviour.

Self-Discovery: Coming to an Expanded Sense of Self: Participants invariably felt that they had made substantial gains in terms of self-discovery, insight, understanding, and personal growth. The process of self-discovery brought an expanded sense of self in which there was room for self-respect, confidence, and openness to others.

Learning for Life: Participants drew attention to the knowledge, skills, and specific tools that they have been able to integrate into their everyday lives. The memory of their experiences at BridgePoint lives very powerfully with participants. Thus, remembering the success that they had had in trying new skills and approaches made it possible for participants to use these skills and approaches in everyday life.

Strengthened Relationships: For some participants, involvement of family members in BridgePoint programs had the effect of strengthening family relationships. Such change was most often attributed to the fact that family members had gained insight into eating disorders and had a greater appreciation of family dynamics that had been problematic.

• Transition from BridgePoint to the Community

The majority of participants felt a great need for ongoing support in moving forward in their recovery process once they had left BridgePoint. The nature and sources of support and their experiences of support in their home communities varied considerably. The four main sources of support were BridgePoint team members, other participants, home team members, and family and friends.
Participants experiences of home team support are very diverse and reflect both the potential for home teams to play an important role in the continuum of care and the substantial difficulties that people face in finding home team members who can effectively support their processes of change. Participants were most likely to find their home teams relevant and supportive when the home team experience was consistent with the approach of BridgePoint and thus, offered an opportunity for them to move forward in the work they had begun in the program.

The Experiences of Family Members

Most remarkable in the stories of family members was the extent to which their experiences mirror those of the participants. Family members also find that their lives are consumed with the realities of living day-to-day with someone who is struggling with an eating disorder. Most struggle with how they can effectively help their daughter, sister, or partner to deal with the eating disorder. Just as it is difficult for participants to take the first steps toward BridgePoint, it is also challenging for family members. The family members who shared their stories with us talked about entering BridgePoint from a place of desperation mixed with hopefulness.
Of central importance in the accounts of family members were the profound differences that BridgePoint had made in the lives of their daughters, partners, and sisters. They drew attention to significant outcomes for participants in terms of personal growth, diminished eating disordered behaviours, and positive changes in family relationships. They also identified outcomes for themselves that they attributed to participation in the BridgePoint program. These included:

• Increased Knowledge and Understanding
• Strengthened Relationships
• Self-Discovery
• Hope

For family members the qualities of BridgePoint that had contributed to these outcomes were essentially the same as those named by participants.

The BridgePoint Practice
Articulating a practice so complex and multi-layered as that of BridgePoint posed a significant challenge. In an effort to represent the practice in all its complexity and yet to convey the simplicity of the underlying themes, three major categories have been used.

• Core Beliefs and Values (The Philosophy of BridgePoint)

Team members are collected by a shared philosophy and a strong commitment to grounding their practice in a common set of beliefs and values. These include:

• An Agreed-upon View of Eating Disorders
• Personal Growth/Change Happens in a Context of Community
• Equality is Essential to a Change Process
• Discovery Leads to a Process of Recovery
• Everybody Has Within Them the Capacity to Change and Grow

• Orientation to Practice

The orientation to practice at BridgePoint reflects the ways in which underlying beliefs and values are implemented as team members interact with participants and family members. While each team member has their own individual practice based on their particular skills and perspectives, they are also engaged in a shared practice that incorporates a number of important qualities.

• Ensuring Safety
• Facilitating Self-Knowledge/Awareness
• Shifting Established Patterns and Beliefs
• Being Meaningfully Connected in Authentic Relationships
• Being With People in Their Process
• Peer Support
• Being Flexible and "In the Moment"

• BridgePoint Program Design

Appreciation of the uniqueness and particular strengths of the BridgePoint program requires an understanding of a number of essential program elements. The residential nature of the program is critical to the intensive, community-based team approach that integrates professional services with peer support. An emphasis on group work allows for participants to engage in a wide range of experiential learning processes oriented toward self-discovery and personal growth. At the same time, one-on-one sessions with team members and informal, non-programmed time also offer important opportunities for learning and change. At the core of the BridgePoint program is the communication model that serves as an overarching framework for all program activities. BridgePoint is also unique in its particular orientation to team work in which team members offer their diverse skills and experiences in ways that transcend boundaries between disciplines. The program design includes a number of structures and processes that support working as a team and that reflect a commitment to accountability.

By including a family and friends component as an important part of its programs, BridgePoint acknowledges the critical importance of the contexts in which people live with eating disorders. Attention to context is also evident in efforts to provide ongoing support for participants through connections with BridgePoint team members and community-based home teams.

Learning from Community-based Counselors

Counselors spoke about gains they saw for participants and family members as a result of attending the BridgePoint program. They drew attention to how, in a very short time, participants moved from an experience of desperation to one of self-discovery and hopefulness. They emphasized some of the key attributes of the BridgePoint program: the holistic nature of the work, the authenticity, the caring and acceptance, and the focus on choice.

Counselors also shed light on some important issues with respect to bridging between the BridgePoint program and the community. They are aware that when participants leave BridgePoint, the euphoria that comes from their substantial achievements in the program is immediately confronted by the reality of day-to-day life.

CHALLENGES: AREAS FOR FURTHER REFLECTION AND WORK

Through the inquiry, a number of areas emerged as challenges for BridgePoint board and team members to take into account as they move forward in strengthening the program.

Most significant were concerns related to bridging between the larger community and BridgePoint. Specifically identified was a lack of knowledge and understanding on the part of community resources as to what BridgePoint has to offer to participants and their families. To the extent that community resources do not understand the philosophy and structure of BridgePoint, there exist barriers both in terms of referring to the program and as regards the effectiveness of home teams. The learning about home teams suggests that BridgePoint may want to consider strengthening its role as regards supporting home team members through offering more extensive information, through outreach efforts, and through fostering connections among home team members.

The learning from this study demonstrates the unique practice that underlies the BridgePoint program and reveals a significantly different way of working with people with eating disorders than is to be found in most other programs. The practice of the BridgePoint team appears not to be well understood in the professional community outside BridgePoint and is sometimes regarded with distrust or suspicion. Although there is evidence that this situation is changing, there is a pressing need to ensure that community practitioners come to trust and respect BridgePoint through recognizing the very real benefits of the program.

UNDERSTANDING RECOVERY

The stories that were shared with us offer profound insight into recovery and clearly confirm that there is nothing linear about the process of recovery from an eating disorder. Through their stories, participants reveal the complex and fluid nature of the healing process. They draw attention to the ongoing struggles to deal with eating disordered behaviours and to create a life that reflects an expanded understanding of self.

Clearly, an understanding of recovery requires a profound appreciation of what it is like to live with an eating disorder – of the difficulty of struggling day-to-day with the pain, secrecy, isolation, and shame that are part of the territory of eating disorders. Moreover, it requires an appreciation of recovery as a journey in which there will inevitably be detours and setbacks and no discernible end point. Among team and board members at BridgePoint, there is a shared understanding that recovery is not about eliminating eating disordered behaviours but about living life differently such that these behaviours diminish over time and may eventually disappear.

CONCLUSION

It is clear that the BridgePoint Program and Practice contributes to making a difference in the lives of participants and family members coping with eating disorders. Perhaps the most profound overall difference is the opening up of a path forward in the process of recovery/discovery.

PREFACE

This report was prepared for the BridgePoint Center for Eating Disorders by Barbara Sykes and Lynda
Workman on behalf of Wolfe-Gordon Consulting. It was a privilege for us to be involved in this evaluative inquiry and to have the opportunity of seeing first-hand the ways in which the BridgePoint program works with individuals living with and affected by eating disorders. We are greatly indebted to the BridgePoint participants who allowed us into their personal processes, shared their stories and their wisdom with us, and reflected on our often difficult questions. We would also like to extend our thanks to the family members and the community-based counselors who shared their experiences and perspectives with us. We acknowledge with thanks the willingness of BridgePoint team members to have their practice examined "under a microscope" and we appreciate the openness of team and board members to reflecting on the BridgePoint program. Finally, special thanks are due to Kelly Wiese and Elizabeth Bailey who generously offered the poetry included here that speaks so eloquently to the experience of living with and recovering from an eating disorder.

APPENDIX ONE: AN ACCOUNTABILITY FRAMEWORK – THE WORK OF BRIDGEPOINT

The framework depicted in Figures 1 and 2 represents the key components of BridgePoint and illustrates the critical links between these components. It is offered here both as a holistic model of the program and as means of addressing accountability.

The framework is oriented to participant-defined outcomes: the achievements or successes that participants and family members named as important in the struggle of living with and recovering from an eating disorder. The outcomes, shown on the left in each diagram, are the "reason for being" of the program; that is, they represent the vision of what BridgePoint is setting out to achieve in offering a supportive program to people living with and affected by eating disorders.
Indicators are the signs of movement or change in relation to identified outcomes. They speak to how we know that we are making a difference and thus, offer evidence of the extent to which desired outcomes are being achieved. Each indicator is a theme arising from the stories of experience of participants and family members. Evidence can include both "positive' and "negative" experiences. It is often "negative" experience that provides direction for program and practice improvements.

The right hand side of figure 1 shows the BridgePoint program and practice as being firmly grounded in a context marked by a profound understanding of the realities of living with an eating disorder. From this understanding comes an appreciation of what is needed to most effectively support recovery from an eating disorder. The BridgePoint program itself is at the centre of the framework representing a conscious and intentional way of responding to what is understood about living with and recovering from an eating disorder. The program is the vehicle that moves understanding and intentions into action. As reflected in this report, the key components of the program are the core beliefs and values that represent the underlying philosophy of practice, the orientation to practice, and the program design.

The component entitled "factors that contribute" reflects the ways in which the program and practice are experienced by participants and family members as making a difference in terms of living with and recovering from an eating disorder. These are the factors that contribute to the achievement of participant-defined outcomes. Figure 2 shows in greater detail, the link between critical program elements and the outcomes to which they contribute (that is, it expands on the components on the left-hand side of Figure 1). Just as the accounts of participants and family members reveal indicators of movement toward outcomes, they also reflect indicators of how the work of BridgePoint contributes to the outcomes. In the material provided here, we have offered some examples of indicators of outcomes and program elements. Many other such indicators are evident in this report and we leave it to BridgePoint board and team members to complete the task of identifying these indicators.

Returning to Figure 1, the broken line represents the dynamic of continuous learning and action that is evident in the BridgePoint program and that is essential in any program to ensure accountability. It is through a mindful and reflective practice that the work of BridgePoint can continue to be relevant and meaningful to participants and family members and to the larger community that it serves. Accountability requires an understanding of desired outcomes as they are defined by participants, program efforts that are directed toward reaching these outcomes, and ongoing learning about the effectiveness of program and practice in moving toward identified outcomes.

APPENDIX TWO: INFORMATION ABOUT INQUIRY PARTICIPANTS*

AGE OF PARTICIPANTS
15-20……………………………………………..4
21-25……………………………………………..3
26-30……………………………………………..4
31-35……………………………………………..2
36-40……………………………………………..3
Age Range: 15-40
Average Age: 27

LENGTH OF TIME WITH AN EATING DISORDER (BEFORE BRIDGEPOINT)
Less than 1 year………………………………….1
1 to 5 years……………………………………….4
5 to 10 years……………………………………...2
10 to 20 years…………………………………….4
More than 20 years……………………………….4
Unknown…………………………………………1
Average Length of Time: 12 years

TYPE OF EATING DISORDER
Anorexia/Bulemia……………………………….12
Compulsive Eating………………………………..2
EDNOS…………………………………………...2

PARTICIPATION IN BRIDGEPOINT PROGRAMS
Orientation………………………………………15
Module One……………………………………...16
Module Two………………………………………9
Retreats……………………………………………6

HOME TEAM MEMBERS
Psychiatrists……………………………………….4
Counselors……………………………………….15
Physicians…………………………………………8
Dieticians/Nutritionists……………………………4

PREVIOUS SERVICES/TREATMENT
Hospitalization…………………………………….8
Dietician services………………………………….2
Individual counseling……………………………..11
Support group ……………………………………..8
Residential program………………………………..1
No other services…………………………………..2

*Includes only program participants. No information is provided on family members.

APPENDIX THREE: BRIDGEPOINT COMMUNICATION MODEL

A Model for Communication

Context(Background) is Everywhere!

Perceptions:
(Five Senses) I see, hear, taste, smell, touch

Interpretations:
(Meanings) I believe, think, assume, interpret, imagine, judge, speculate, wonder

Feelings: POSITIVE ---- like, love, open, warm, attracted,
(felt in the body) comfortable, move toward
NEGATIVE --- dislike, hate, closed, cool, repulsed, uncomfortable, move away

Intention: I am telling you because, What I feel like doing, intend to do, want to do, will do

Action: What I do

© Bennet Wong M.D. and Jock McKeen M.D., The (New) Manuel For Life, PD Publishing, 1998