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Stepping Down (and Stepping Up) the Treatment Ladder

Exploring the different phases of eating disorder treatment and recovery

Eating disorder treatment is complex, multi-tiered, overwhelming, and full of surprises. No one approaches treatment the same way. The following article will break it down into bite-sized pieces in hopes that readers who find themselves making decisions about treatment will feel empowered to take those critical initial steps. 

There is no particular “right way” or even typical way to start treatment. Where an individual enters the treatment process depends upon the level of care they need and the resources available. Each level of care offers a particular level of support, like scaffolding, that allows the patient time to reach certain recovery goals. Once the goals are met, “scaffolding,” or support, is removed and the patient tries to move down the ladder to a lower level of care. For the sake of clarity, we will begin at the “top” of the ladder but it must be understood that many clients do not start this way. 

Inpatient Hospitalization

Inpatient hospitalization is the highest level of care. The focus is medical stability and the beginning of weight restoration. Patients requiring inpatient hospitalization present with abnormal lab values, irregular cardiac rhythms, gastrointestinal concerns and typically long histories of disordered eating. Being admitted to the hospital for the treatment of an eating disorder is a terrifying prospect for patients and family members. This is in part because the patient, often for the first time, is faced with the severity of the disorder. Additionally, being admitted to the hospital means strict feeding protocols will be in place and to the malnourished brain, this is experienced as a threat. Sometimes, but not always, feeding tubes are placed to provide the highest level of support to patients that need it. Inpatient hospital stays are typically short, lasting a few days to weeks, as the treatment team plans for the next level of care. 

Residential Treatment Facilities

Inpatient hospitalization will ensure a patient is medically stable but will not address the deeper issues of the eating disorder. No one leaves an inpatient stay “fixed.” The therapeutic work begins at the next level of care called residential treatment.  A typical patient stay is between 2-4 weeks. Treatment focuses on weight restoration while inviting the patient to push back against food rules and phobias. Residential care provides a high level of support with all meals and activities monitored. The patient is urged to experiment with “forbidden” foods and to experience, within the supportive context of the treatment facility, that many of their fears are unfounded.  Many different therapy modalities are used by therapists, dietitians and social workers to help the resident dismantle their unhelpful coping strategies and to develop new ones.

Upon entering residential treatment, the patient will often be resistant, paralyzed by the fears of having their food and compensatory behaviors monitored for an extended time. On the other side of the residential stay, patients often reflect deep relief and gratitude that they were “forced” to engage in treatment. Consistent nourishment, intensive therapy, shared experiences with other residents and the removal of day-to-day stress will help the resident come back to themselves. At the same time, it is important to note that patients are not discharged from residential care fully rehabilitated. Often, patients will still require meal-time support and weight restoration, but after residential, these goals can be achieved in an outpatient setting. 

Partial Hospitalization Program (PHP) 

At this point, the client is ready to step down to a lower level of support in the partial hospitalization program. Typically, participants attend a program for 6-10 hours per day with evening meals at home. This model allows the patient to gradually experience some triggering situations while still maintaining a high level of support during the day. Patients are typically reliant on a meal plan at this point and they are encouraged to gradually take on more decision-making as the program progresses. Special meal time outings and restaurants are often a part of the PHP and participants continue to challenge their food phobias. The PHP also offers therapeutic meal planning, food prepping, and cooking support to help clients re-engage these skills that are often lost during long bouts of disordered eating. 

Intensive Outpatient Program (IOP)

Patients are now encouraged to re-engage with other aspects of their lives and allow treatment to take a side seat. The IOP is a few hours per day with school, work, and family moving back into the primary focus. Inevitably, this increases stress and uncertainty, and recovery continues to be a challenge. The IOP takes on the role of a “process group” where participants can share how they feel about re-entering their lives more fully.

At this stage, parts of the meal plan are often adjusted to encourage more decision-making and steps toward intuitive eating. Social eating and spontaneity are reintroduced, and clients begin eating unsupervised meals or even making meals for the family. Clients can participate in IOP for a few weeks or a few months, depending on their needs and the recommendations of their treatment team. 

Outpatient Treatment

This level of care offers the least support. Nearly all the scaffolding is removed and the client is responsible to manage their own care. This requires building their own support team including a dietitian, therapist, primary care provider, and psychiatrist. The client can expect 2-3 hours of support per week. Besides one-on-one counseling, clients are encouraged to participate in support groups and online forums to stay engaged in the healing process. Depending on the client, the nutrition goals may include a meal plan or some form of dietary tracking, and in some cases, the client is ready to move away from these structures and practice intuitive eating. Relapse prevention is a key emphasis of this phase of treatment as patients often find themselves pulled back to certain behaviors by daily stress, the pressure of diet culture, or family conflict. Continued participation in treatment is essential and can last many months as the client works on deeper issues surrounding anxiety, body image, and relationship dynamics. 

How Does One Move Through the Treatment Ladder?

In a perfect scenario, a patient would present for care, be assessed, and then directly referred to the appropriate level of treatment. The care facility would then quickly admit the patient and they would seamlessly travel down the ladder of care. Unfortunately, real life is far more complicated. Financial constraints, insurance companies, misdiagnoses, waiting lists, unsupportive families, relapse, lack of access, and resistant clients each complicate entry into treatment. In turn, the recovery process is rarely a clear progression down the ladder but usually involves traveling up and down.

Let’s consider a few real-life examples of how a patient might experience treatment:

  1. A dietitian voices concern over a client’s behaviors and weight fluctuations and urges the client to be assessed for residential treatment. The client is dismissive and states that they are “fine” and will not consider a higher level of care. The client remains in outpatient therapy and only receives a few hours of support each week as their eating disorder declines. They are then hospitalized for in-patient care.
  2. A client discloses to a therapist that they have recently lost a significant amount of weight and their partner is concerned about their meal skipping. The client takes the therapist’s recommendation and is evaluated for a higher level of care, only to discover that their medical insurance will not cover the cost of the necessary treatment.
  3. A parent brings their child for an annual checkup. They are told that they have “fallen off” their growth curve and are no longer growing at the same rate as the years before. Upon further inquiry, the family discloses a pattern of meal refusal, calorie counting, and 2-3hrs of exercise per day. The provider refers the family to a dietitian for a meal plan when she should have been referred to residential treatment. 
  4. A family makes the difficult decision of sending their daughter to residential treatment, only to find out there is a waiting list. They are referred to outpatient care as they wait for an opening.
  5. Upon graduating from residential treatment, a client finds out that their insurance will not pay for PHP or IOP. They move from full-time residential care to only a few hours per week of support. 

As you can see, getting the correct treatment for yourself or for your loved one requires determination, patience, and support. Each journey is different and while you can learn from the stories of others, it is not helpful to expect your story to be the same. Help is out there. The National Eating Disorder Association has a hotline to answer questions about treatment in your area. The International Association of Eating Disorder Professionals has a directory of eating disorder providers across the US. Begin asking questions and making inquiries into care options. Do not let, “I don’t know where to start,” be a reason to delay treatment. Start your journey today.

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