Eating Disorders:
When Outpatient Treatment Is Not Enough

continued

Hospitalization should not be regarded as an easy or final solution to an eating disorder. Minimally, hospitalization should provide a structured environment to control behavior, supervise feeding, observe patient after meals to reduce purging, provide close medical monitoring if needed, and, if necessary to save a life, provide invasive medical treatment. Ideally, treatment programs for eating disorders should offer an established protocol and a trained staff and milieu that provide empathy, understanding, education, and support, facilitating cessation or dramatic reduction of eating disorder thoughts and behaviors. For this reason, hospitalization does not have to be a last resort. In fact, professionals should avoid the connotation that indicates, "If you get too bad, or if you don't improve, I'm going to have to hospitalize you, and I know you don't want that." Hospitalization should not be feared nor should it be seen as a punishment. It is better for individuals to understand that if they are unable to battle their eating disorders with outpatient therapy alone, then more help for them will be sought in a treatment program where they will be provided the care, nurturing, and added strength they need to overcome their oppression by their eating disorders. When framed to the patients as "an opportunity to take the necessary time out from other responsibilities to focus on recovery in a setting where your thoughts and behaviors are understood," hospitalization or some other round-the-clock treatment option can be viewed as a welcomed, albeit scary, choice individuals make from the healthy part of them that wants to get better.

Letting eating disordered individuals be included in all of their treatment decisions, including when to go to a treatment program, is valuable. Control issues are a consistent theme seen in individuals with eating disorders. It is important not to let a "me against them" relationship develop between the therapist or treatment team and the person with the eating disorder. The more control individuals have in their treatment, the less they will need to act out other means of control (e.g., lying to the therapist, sneaking food, or purging when not being observed). Furthermore, if an individual has been included in the decision-making process regarding hospitalization or residential treatment, there is less trouble getting compliance when admission is necessary. Consider the following example.

Alana, a seventeen-year-old high school senior, first came in for therapy when she weighed 102 pounds. Alana's mother brought her to see me because of her concern for Alana's recent weight loss and her fear that Alana was overly restricting her food intake, having taken her diet too far for her 5' 5" frame and her propensity for exercise. Alana was reluctant and angry that her mother had dragged her to a therapist's office; "It's my mother who has a problem, not me. She won't get off my back."

I sent Alana's mother out of the room and asked Alana if perhaps there was anything I could possibly help her with since she and I both had at least another thirty minutes to kill. When Alana couldn't really think of anything, I suggested that one thing I might do is help her get her mother off her back. This, of course, perked her up a little and she immediately agreed. After talking to her for a while and explaining how I work on getting parents to stay out of their kid's eating, I invited Alana's mother in and explained to both of them that, for right now, as long as Alana was going to be seeing me there would be no reason for her mother to discuss her eating habits or her weight. Her mother was unhappy about this and offered several protests, but I held firm that this was no longer her territory and that her involvement in fact made matters worse, which she conceded. However, Alana's mother needed reassurance that Alana would not be allowed to starve herself to death, which was an almost obsessive fear for this parent due to the recent unexpected death of her husband. Therefore, I told them that I would not allow Alana's condition to worsen without more intense intervention and that I was sure Alana had no intention of that, either. Here is where I let Alana in on a major treatment decision:

Carolyn: Alana, at what weight do you think you would need to be hospitalized?

Alana: I don't know, but I'm not going to let that happen. I'm not going to lose any more weight. I've already told everybody that. I don't need to go to a hospital.

Carolyn: Okay, so you've agreed to not lose more weight, but you're a smart girl. To reassure your mom, let her know that you do have some idea of what would be unreasonable or unhealthy to the point where you would need to go to a treatment program for more help.

Alana: (Fidgeting a bit and looking uncomfortable, not willing to say anything, most likely for fear of being trapped and held to it.)

Carolyn: Well, do you think 80 pounds would be taking it too far? Would this be so low that you need to go to a hospital then?

Alana: Of course, I'm not stupid. (Most, but not all, anorexics think they can control the weight loss and don't imagine they will ever be at the extreme weight often seen in other anorexics.)

Carolyn: I know, I already said I thought you were smart. So do you think 85 pounds would be too low?

Alana: Yes.

Carolyn: What about 95?

Alana: (Now Alana really squirms. She is trapped. She doesn't want to continue this, as it is getting too close to her current weight and perhaps she desires to lose "just a little bit more.") Well, no not really. I don't think I'd need a hospital or anything but it's not going to happen anyway.

Carolyn: (At this point I know I have her in a position to settle on a weight criterion for going into a treatment program.) Okay, so I think we can agree that you think that 85 is too low but 95 is not, so somewhere in between there you would cross the line where outpatient therapy wouldn't be working and you'd need something else. In any case, you are willing to stay at your current weight of 102. Is that right?

Alana: Yes.

Carolyn: So then for your mom's sake and since you have said you will not lose any more weight, let's make an agreement. If you do lose weight to the point where you get down to, say, 90 pounds, you will in essence be telling us that you cannot stop and therefore you need to go to a treatment program?

Alana: Sure, yeah, I can agree to that.

Throughout this discussion Alana played a major role in decision making for her treatment. She got to have her mom "off her back," and she helped determine the weight criterion for hospitalization. I did have to spend some time with Alana's mother to reassure her that this was the best approach and that letting Alana in on this criterion would help us out in the event that hospitalization was necessary. I also wanted to give Alana the chance to maintain her weight and improve her diet through outpatient therapy. However, in Alana's case, the writing was on the wall. All of Alana's behaviors described to me earlier in the session by her mother pointed to the fact that she probably would indeed continue to lose weight because, as with most anorexics, her extreme fear of gaining would keep her restricting to the point where she would most likely continue to lose. Alana did get down to 90 pounds and reluctantly, though compliantly, went into a treatment program. The process of having Alana establish the weight criterion made a huge difference in her willingness to go when it became necessary. Additionally, there was no panic or crisis when the time came, and the therapeutic relationship bond was not disrupted by me "doing something to her" or fostering the "me against them" attitude I discussed earlier. I reminded Alana that she herself had agreed that if her weight were to get this low, it would mean that she needed more help.

In Alana's case there was no medical condition or emergency situation necessitating hospitalization. Rather, hospitalization was followed through with when outpatient therapy was not working and an eating disorder treatment program was a means for her to get the help she really needed to get better. A good eating disorder program provides not only structure and monitoring but also a number of curative factors that facilitate recovery.

CURATIVE FACTORS OF INPATIENT OR RESIDENTIAL TREATMENT

(The term patient or inpatient will be used to refer to an individual in a round-the-clock treatment program, and the term hospital, or hospitalization will refer to any round-the-clock program.)

A. SEPARATES PATIENT FROM HOME LIFE, FAMILY, AND FRIENDS

• Family members may have had a significant role in the development or sustaining of the disorder. Secondary gains with the family or with friends may be exposed and may even diminish when patients are removed from those people.

• The therapist can take a more active role as both authoritarian and nurturer and facilitate the necessary trust and relationship needed for recovery.

• When the patient is absent from the family, the therapist can see the functional significance that the patient had in the family. The "role" the patient plays in the family may be an important aspect of treatment. Furthermore, how the family functions without the patient will be helpful in determining causes and treatment goals.

• Being away from normal routines such as work, taking care of children, and daily living responsibilities, which often serve as distractions from dealing with the issues and behaviors, can help patients to focus attention where it is needed.

B. PROVIDES A CONTROLLED ENVIRONMENT

• Putting a patient in a controlled environment exposes otherwise hidden issues such as food rituals, laxative abuse, rigidity in eating behaviors, mood around mealtimes, reactions to weighing, and so on. Exposing the patient's true patterns and behaviors is necessary in order to deal with these issues, discovering the meaning they have for the patient and finding alternative, more suitable behaviors.

• A controlled, structured environment assists the patient in breaking addictive patterns. Popcorn and frozen yogurt diets will not be able to be continued. Vomiting directly after meals will be difficult in programs providing direct supervision after meals. Weight is usually monitored and yet kept from the patients in order to protect them from their own reactions to the information and to break them from being addicted to weighing and to the number on the scale. Furthermore, having a certain schedule to follow, including planned meals, helps reintroduce structure into what is often a chaotic pattern. A healthy, realistic schedule may be learned and then utilized on returning home.

• Another useful aspect of the controlled environment is medication monitoring. If medication is warranted, such as an antidepressant, it can be more carefully monitored as to compliance, side effects, and how well it is working. Observation of the reaction to medication, blood tests, and dosage adjustments is more easily carried out in a hospital setting.

C. OFFERS SUPPORT FROM PEERS AND A HEALING ENVIRONMENT

• Patients in a treatment program are there with other individuals with similar issues, problems, and feelings. The camaraderie, support, and understanding of others are well-documented healing factors.

• A good treatment team in a hospital also provides a healing environment. Its members can be positive role models for self-care and can be an example of a healthy "family" system. The treatment team can provide a good experience of the balance between rules, responsibility, and freedom.

The duration of time spent in a treatment program will depend on the severity of the eating disorder, any complications, and the treatment goals. Inpatient treatment dealing with the eating disorder should include family and/or significant others throughout its course unless the treatment team determines there is good reason not to do so. Prior to discharge, family members can work with the treatment program staff to establish treatment goals and realistic expectations for the entire family.

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Hospitalization can help break any addictive patterns or cycles and start a new behavioral process for the patient, but it is not the cure. Long-term follow-up is necessary. Success rates for hospitalization are hard to come by, but there are many aspects to choosing the right program, which will not be the same for everybody.

The cost of inpatient treatment is anywhere from $15,000 to $45,000 per month or more, and, sadly enough, many insurance companies have exclusions in their policies for eating disorder treatment, which some have referred to as a "self-inflicted" problem. Careful assessment of cost and reimbursement possibilities should be done prior to admission unless there is an emergency situation. This is an outrage to people familiar with those suffering and/or those treating these individuals. There are some recovery homes or halfway houses that charge far less, even as little as $600 to $2,500 per month. However, these programs are not as intense or highly structured and are inadequate for individuals needing higher levels of care. These programs are useful as a step down from more intensive treatment. When considering admission to a treatment program it is important to review the philosophy, staff, and schedule of various program options. To help patients and their families in the selection of an appropriate treatment program, the following "ingredients" were developed by Michael Levine, Ph.D.

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