BRIDGEPOINT CENTER for EATING DISORDERS:
DEVELOPING A PROCESS AND TOOLS FOR ONGOING EVALUATIVE INQUIRY

FINAL EVALUATION REPORT FOR 2004

EXECUTIVE SUMMARY
January 2005

 

                                      BridgePoint Report of Evaluation Inquiry 2004
                                        Prepared by:
                                                          Barbara Sykes and Ann Goldblatt

This poetry… with grateful acknowledgement to the authors... participants…BridgePoint  has the privilege to serve – in honor of the courage to share yourselves, experiences and stories.

BRIDGEPOINT CENTER FOR EATING DISORDERS:
DEVELOPING A PROCESS AND TOOLS FOR ONGOING EVALUATIVE INQUIRY

FINAL EVALUATION REPORT FOR 2004

EXECUTIVE SUMMARY

BridgePoint Center for Eating Disorders was established in 1995 to offer a multi-faceted, intensive, residential recovery program for individuals living with eating disorders. In keeping with a longstanding commitment to evaluation, in 2002 BridgePoint initiated an evaluative inquiry process with the aim of gaining a deeper understanding of the impacts of BridgePoint programs with participants. The current project (Developing a Process and Tools for Ongoing Evaluative Inquiry) builds on and extends the learning from the 2002 evaluation. The purposes of this inquiry were:
 
·*to develop a framework naming outcomes and indicators of BridgePoint practice and programs
·*to develop a process and tools by which evaluation can be undertaken on an ongoing basis
·*to implement the evaluative tools in a process of data collection involving BridgePoint participants and family members/friends (those involved since the 2002 evaluation)

EVALUATION FINDINGS: SUMMARIZING THE LEARNING

PART ONE: LEARNING ABOUT OUTCOMES

The key focus of the evaluation was on learning about the outcomes of participation in the BridgePoint program; in other words, what difference did programming make for those who attended BridgePoint (both as participants and as family/friends)? This section of the report draws on the accounts of survey respondents to identify the impacts of BridgePoint in terms of the desired outcomes named in the Accountability Framework (see Appendix).

A. Outcomes for Participants

Changes in eating disordered behaviours
· Findings point to a significant increase in the extent to which participants were aware and conscious of their eating disorder as a result of being at BridgePoint. Their learning helped participants to:
- acknowledge and analyze disordered eating episodes and to come to terms with having an eating disorder
- move beyond a state of denial and acknowledge their eating disorder
- see their eating disorder from a different perspective
· *For most participants BridgePoint fostered an increased awareness of the choices they had around disordered eating behaviours and confidence in their ability to make changes in their lives. However, a substantial number of participants continued to struggle with making the concept of choice real and meaningful in their lives.
· *Most participants were able to act on different choices and make more conscious choices, particularly in terms of changing eating patterns or trying different foods.
· *Participants were able to talk more openly about their eating disorders with people they trust and, in some cases, had developed closer relationships as a result of being able to talk with family and friends.
· *Most participants were able to take more responsibility for their own behaviours: making decisions for themselves, not for others.
· *Some participants experienced a decrease in eating disordered behaviours and in some cases, this change was very profound. Equally as many reported little or no change.
· *For the great majority of respondents, participation in BridgePoint had contributed toward their process of recovery from an eating disorder. This is an important finding because it reflects the fact that recovery from an eating disorder is not only about changes in eating behaviours but also about feeling more positive about oneself and developing effective coping skills.

New knowledge and skills
· *Most participants reported increased knowledge and understanding of eating disorders particularly about healthy and safe foods. Some however, made a point of saying that their learning about healthy eating and body image had been minimal and that they were hoping for more of an emphasis on these areas.
· *Responses clearly reflect an outcome of increased knowledge and understanding about how to deal effectively with anxiety and stress. However, many respondents indicated that change was limited and identified a need for more learning about dealing with anxiety and stress.
· *Participants were very positive about the extent to which BridgePoint had increased their knowledge and understanding about communication skills and coping skills. Some respondents spoke to the impact of their improved communication skills in terms of strengthening important relationships. In addition, many commented on the power and efficacy of the communication model used in BridgePoint programming.
· *There is evidence that participants were able to apply their new skills in their everyday lives in a diversity of ways. For some this meant finding ways to cope with stressful situations and for others it meant using new communication skills to improve relationships.
· *For some participants, BridgePoint has resulted in an increased sense of control over their lives, enhancing their confidence about managing their lives and making healthy decisions. It is important to note however, that some participants clearly did not experience any greater sense of control in their lives as a result of BridgePoint and that feeling "out of control" is an issue that remains to be addressed for them.
· *Since being at BridgePoint, the majority of participants have maintained relationships with supportive others. These participants talked about feeling more connected, having deeper or stronger relationships, and feeling less isolated.
· *Being at BridgePoint seems to have increased the likelihood of participants being able to ask for help when they need it. The majority of participants indicated that it had become easier for them to ask for and accept help. However, a significant proportion indicated that there had been no change for them in this respect. Some participants voiced uncertainty as to whether BridgePoint was intended to be source of help once they had gone home. 
· *Evaluation data clearly point to an outcome of enabling participants to acknowledge their feelings and express them more openly.

Understanding of self
· *Judging by the comments offered by participants, the greatest impact of BridgePoint may have been in fostering self-discovery and personal growth.
· *Asked about whether their experience at BridgePoint had helped them to discover more about "who I am", nearly all participants answered in the affirmative. Some had tapped into areas of creativity such as art, music, and crafts. Many spoke to an experience of recognizing "who I am and what I have to offer to others." Self-understanding was also defined in terms of finding ones' voice.
· *An outcome for a large proportion of participants was experiencing more positive thoughts and feelings about themselves. This change was voiced in terms of increased self-esteem and confidence and being more able to love oneself. Respondents talked about being less inclined to be self-critical and about treating themselves with more care and compassion.
· *Participants had experienced some success in shifting their focus from disordered eating behaviours to more important activities and interests. However, it is apparent from the evaluation responses that this was a challenge for most respondents.
· *For some participants, an outcome of BridgePoint was that they were living life more fully and life was more meaningful for them. These participants voiced their perceptions of enjoying life, living more honestly, and taking pleasure in things that were important to them. Some participants felt that they were just beginning this journey and others perceived little or no progress along this path.

Strengthened relationships
· *Participation in BridgePoint programming helped most respondents to work out relationship issues with important people in their lives. Learning from BridgePoint offered an understanding of the dynamics of relationships and helped participants to recognize what was important to them in their own relationships.
· *Evaluation findings suggest that BridgePoint had a significant effect in terms of participants feeling more positive about their relationships and more connected with other people in their lives. In particular, a number of  participants viewed the bonds they had formed with other women in their programs as a significant outcome.
· *The majority of participants responded that they had experienced their home team as supportive. However, it is important to note that some respondents did not have a home team or did not feel a supportive connection with home team members.

Family members/friends were asked to share their perceptions of what difference BridgePoint made for the participant involved in the program. Several key themes emerged from the responses including:

· *Increased awareness: of self and eating disorders · Enhanced self-esteem
· *A more positive state of mind: more happy and/or relaxed · Increased openness
· *Availability of tools to use in everyday life · Hope

B. Outcomes for Family and Friends

Increased knowledge and understanding
· *Virtually all of the family members/friends who responded to the questionnaire affirmed that their knowledge and understanding about eating disorders had increased as a result of being at BridgePoint.
· *Participating in BridgePoint programming had helped family members/friends to be more understanding and accepting of their family member/friend who has an eating disorder. They talked about the experience as being "eye-opening" and "a revelation" and as offering invaluable insights into what it is like to live with an eating disorder. Their learning offered them a different perspective on the behaviours of the participant that translated into a greater degree of acceptance and empathy.
· *An outcome of participation in BridgePoint for most family members/friends was that they had become more aware of how their own actions may be related to the disordered eating of their family member/friend. 
· *As a result of their experiences at BridgePoint, the great majority of family members/friends were more able to see the whole person, not just the eating disorder.
· *For most family members/friends, participation in BridgePoint allowed them to see ways of being more supportive to the participant. Several drew attention to their learning about communication as a key to being supportive. Inclusion of family/friends in the BridgePoint program (in contrast to non-inclusion in other treatment programs) was identified as critical in helping respondents to discover ways of being more supportive. 

Strengthened relationships
· Most family members/friends indicated that BridgePoint had increased their capacity to respond more effectively to their family member's (friend's) eating disorder.
· Being at BridgePoint had the effect for most family members/friends of strengthening their relationships with their family member/friend with an eating disorder. For these respondents, the relationship had matured or become more open. Communication was identified as a key to strengthened relationships.
· Although the extent of change may not have been large, most family members had noticed changes within their family (e.g. communicate more effectively, address problems openly, flexible problem solving, respect of differences).

Self-discovery
· *As a result of their experiences at BridgePoint, most family members/friends said they were aware of personal growth for themselves.  The program was seen as offering opportunities for learning and for personal fulfillment.
· *Evaluation findings point to increased awareness and understanding of "who I am" among family members/friends. They talked about becoming more attuned to their own feelings, of discovering their own strengths, and of becoming more aware of their personal issues.
· *For the most part, respondents felt that, as a result of being at BridgePoint, they had become more able to talk about and deal effectively with own issues.
· *An important outcome for virtually all respondents was that they felt more hopeful about the future and could see potential for the recovery of their family member/friend.  However, the responses to this question clearly reflect feelings of ambivalence that appear to be common among family members/friends of participants. On the one hand, they recognize and feel hopeful about the progress made by the participant toward recovery, yet on the other hand, they are acutely aware of and frustrated by the lengthy the process of recovery from an eating disorder.
· *Several respondents noted an outcome of increased comfort and a feeling of solace that emerged from knowing there is a place where their family member/friend can get help and where they themselves can talk to others in similar situations.

PART TWO: LEARNING ABOUT IMPORTANT ELEMENTS OF THE PROGRAM

Important Elements for Program Participants

The following program elements are shown in order of the level importance given them by program participants

· *Being treated with care, compassion and respect by team members
Participants described team members as understanding, compassionate, trustworthy and non-judgemental, and emphasized that they had been treated as equals by team members.
· *Experiencing a sense of belonging at BridgePoint through a sense of connection with others (team members or other participants)
Most participants found these connections to be an invaluable source of ongoing support.
* Being understood and accepted for “who I am”
Participants' responses and comments speak to the extent to which they felt understood and accepted by team members and other participants, in some cases "for the first time ever". 
· *Being in an environment that is conducive to safety and comfort
Most participants experienced a profound sense of safety and comfort at BridgePoint. Participants talked about the extent to which the sense of safety provided a context for working toward recovery. They felt that they could share their fears and anxieties without being judged. In a few cases, participants drew attention to experiences in which safety was lacking. Their examples related primarily to food (too much of it) and to being around the kitchen.
  *Having team members to talk to when needed
Participants found team members to be readily accessible, trustworthy, and responsive to their needs. They could talk openly with team members with the expectation of being heard and not judged. However, this was not true for all participants. A few felt that team members were less accessible than they might be or did not feel comfortable confiding in them.
· *Experiencing team members as trustworthy and non-judgemental
Team members were viewed by most participants as decidedly trustworthy and as safe repositories of confidential information. Their trustworthiness enabled participants to share sensitive and private matters knowing that their confidence would be respected.
· *Experiencing "being in it together" with other participants working toward similar goals
Realizing that they were not alone and that others shared their struggles was a powerful element of the program for participants.
· *Experiencing "normalcy" through hearing the experiences of other participants and team members at BridgePoint.
Respondents talked about the positive impacts of being understood by others, speaking the same language, and realizing that they were not "crazy." Having ones' eating disorder normalized was valuable in "helping to dispel secrecy and guilt."
· *Being"held able" to make one’s own choices and be responsible for own issues.
Several respondents commented on the fact that this was the first time that they had been held responsible to this extent for making their own choices and that it represented a "totally new way of thinking".
· *Gaining a belief in recovery from an eating disorder through hearing the personal stories of BridgePoint team members
Such stories were meaningful to participants in offering hope for their own recovery and inspiration for their continued efforts toward positive change.
· *Being supported by team members and other participants in identifying choices and making decisions
Some participants contrasted this approach with other treatment models in which they had been given little or no choice about what to do.
  *Having a home team that has been helpful in fostering a process of recovery
Many participants named counsellors and therapists as being instrumental in their recovery efforts. However, a significant number of respondents noted that they had received little or no support from their home team or that they did not have a home team to turn to for support.

Important Elements for Family and Friends

· *Family members/friends attributed their positive experiences of BridgePoint largely to the qualities of the team members. They experienced team members as trustworthy, non-judgemental, caring, compassionate, accepting, and authentic. The fact that many team members had experienced eating disorders themselves and were willing to share their stories was instrumental for family members/friends in helping them to understand eating disorders and to have hope for the recovery of their loved ones
· *As was true for most participants, family members/friends felt a sense of safety associated with being at BridgePoint.
· *An important and valuable element for most family members/friends was the opportunity to meet and interact with others in similar circumstances. Through sharing their stories and their feelings, these respondents understood that they were not alone with their pain and anxiety.
· *With few exceptions, family members/friends felt included in the recovery process. For the most part, they noted that they had been offered support in dealing with their own issues.
· *An element that made a difference for many respondents was seeing the ways in which team members interacted with their family member/friend. These respondents drew attention to the understanding, patience, and trust shown by team members.

Family members/friends identified other elements of the BridgePoint program that they considered important. These included:

· *the residential nature of the program
· *the location of the facility
· *the program approach and philosophy
· *flexibility in program structure and processes

PART THREE: LEARNING ABOUT STRUGGLES AND CHALLENGES EXPERIENCED BY PARTICIPANTS

Recovery from an eating disorder needs to be understood as a complex process - a journey on which there are many markers of progress but also inevitable setbacks and ongoing struggles. Personal challenges and struggles identified by participants include:

· *Ongoing struggles with eating behaviours. Participants spoke about the fear of not having control over their eating, about relapsing into old patterns, about the difficulties posed by making healthy food choices, and about dealing with hunger.
· *Struggles with self-esteem. Respondents talked about the difficulty they had in accepting or loving themselves or in feeling confident about who they are. Some participants linked low self-esteem specifically to body image and weight issues.
· *Feelings of stress, anxiety, depression and lack of happiness. While some respondents struggled with these feelings intermittently, others noted that they were ever present. They talked about worrying and about fear of the future. Some drew attention to their struggles with loneliness.
· *Circumstances of their everyday lives. Respondents noted that they were facing a diversity of issues including financial stress, job related stress, health issues, lack of personal space and time, the impacts of past physical or sexual abuse, and the demands of caring for family members, often including young children.
· *Isolation. Some participants attributed difficulties in making change to the isolation they experienced away from BridgePoint. For these respondents, lack of social support or the absence of anyone to act as a mentor meant that they felt "stalled" in the process of recovery.

Participants also named challenges related to BridgePoint programming. These included:

· *Family and friends component. Some respondents noted that they had no one who they could invite to the family and friends weekend. Others had invited family members or friends who had chosen not to come. Having no family members or friends attend these sessions was challenging for some participants who voiced feeling of sadness, disappointment and loneliness. A few participants who did have family members attend observed that having family members present had been more difficult and stressful for them than had they not been present.

· *Issues relating to food and eating at BridgePoint
Respondents raised a number of concerns regarding food and eating. For some participants and family members/friends, the large quantity of food available, the absence of limits on food consumption, and the nature of the food (for example,
many sweet foods) were problematic for people dealing with eating disorders. Another issue relating to food was the tendency of some participants to eat "more than their share" of food leaving insufficient quantities for others.

· *Follow-up and support. A significant number of participants voiced concerns about the adequacy of follow-up support. In particular, several expressed uncertainty about whether BridgePoint team members were meant to be accessible when support was needed. Although many participants found their home teams to be helpful and supportive, responses suggest that some participants did not have home teams or, in some cases, did not know what a home team was. Also of concern is the knowledge that some participants felt that they had lost or were losing the positive impacts of BridgePoint as time passed after finishing a program. The expressed need for more ongoing support and follow-up indicates the importance of addressing these issues.

· *Unmet hopes and needs. Although these were very few, they were voiced by participants in a spirit of enhancing BridgePoint programming. Most often mentioned by participants was that they had hoped to get individual meal plans as well as ideas and suggestions for healthy eating. Some participants said that they had hoped for a more significant impact in terms of letting go of their eating disorder and losing or gaining weight. However, their responses reflected an understanding that these expectations were not entirely realistic. Another theme that emerged was the hope for more ongoing support and follow-up. Although it was not always specified, we assumed that these respondents were referring to follow-up from BridgePoint team members.

REFLECTIONS ON THE LEARNING

Through their responses to the questionnaires and interviews, participants powerfully confirmed the effectiveness of BridgePoint programming in promoting their recovery from an eating disorder. For many, the difference that BridgePoint had made in their lives was profound.

The outcomes and indicators named in the accountability framework were strongly validated in participants' responses about the impacts of BridgePoint programming. Perhaps most notable in terms of outcomes was the strong indication that BridgePoint had contributed toward the process of recovery for the great majority of participants.

The voices of participants make visible the complex and difficult journey of recovery from an eating disorder. A recurring theme was that of having made progress or moved forward on the path to recovery while at the same time
recognizing that the journey was far from over. Not surprisingly, the stories of
participants reflect a wide variation in the extent to which they experienced movement toward recovery as a result of BridgePoint programming. For some participants, becoming more aware of their eating disorder, being able to talk about it, and gaining more knowledge about eating disorders represented significant progress. Others credited BridgePoint for a significant decrease in eating disordered behaviours to the point that they had essentially recovered from their eating disorder.

Going Forward:
What is Needed to Strengthen BridgePoint Programming

Participants and family members/friends indicated a number of ways in which BridgePoint programming could be strengthened: 

1. Including more learning about healthy eating to promote recovery as well as more practical help in developing individual meal plans.

2. Introducing more structure around eating, and placing more limits around the availability of food. Also, providing an enlarged dining area to allow participants to eat together.

3. Ensuring that programs are responsive to diversities – including type of eating disorder, body size, age, and degree of extremity of one’s eating disorder.

4. Ensuring ongoing support and follow-up, including: greater clarity about the roles of BridgePoint team members as a resource to participants on an ongoing basis, more consistent efforts to stay in connection with participants, and a deeper commitment to creating effective home teams. Also, offering more help to participants in dealing with their issues in the real world.

5. Adjusting program structure/content to include more physical activity for the purposes of learning more about exercise, promoting stress relief, and decreasing the amount of time spent sitting.

6. Offering more information to family members/friends about:
- what to expect from the family and friends component
- how they can help their family member/friend in dealing with disordered eating behaviours, making healthier food choices, or moving toward greater self-awareness

7. Offering more opportunities for family members/friends to participate in personal, one-on-one time with a counsellor, couple-time counselling, sessions with participant and family members, retreats for couples, and group sessions for family members.