Eating Disorders:
When Outpatient Treatment Is Not Enough

Eating disorder treatment is a long-term process involving a potentially life-threatening situation. Treatment is extremely expensive with therapy most likely extending well over two years. Most eating disorder treatment takes place on an outpatient basis. Outpatient therapy refers to individual, family, or group therapy sessions taking place in a therapist's or other professional's office and is usually conducted one to three times per week. Individual sessions generally run forty-five minutes to an hour, and family or group sessions are usually sixty to ninety minutes. Sessions can be arranged for more or less time if needed and as deemed appropriate by the treating professional. The cost of outpatient treatment, including therapy, nutritional counseling, and medical monitoring, can extend to $100,000 or more.

There may come a time when outpatient treatment is insufficient or contraindicated due to the severity of the eating disorder. Treatment in a more intense structured setting, such as a hospital or residential facility, may be required when symptoms are out of control and/or the medical risks are significant. If treatment necessitates a round-the-clock or more acute program, such as an inpatient hospital stay, this alone can be $30,000 or more per month with some patients needing several months or repeated hospitalizations.

Most people consider a treatment program as a last resort; however, if specifically designed for eating disorders, this kind of program can be an excellent option even in the beginning of treatment. There are a variety of settings that provide more intense levels of care than outpatient therapy. When looking for a treatment program it is important to understand the difference between the intensity and structure of different levels of care. The various options include inpatient, partial hospitalization or day treatment programs, residential treatment facilities, and halfway or recovery houses. These options will be described below.

TREATMENT PROGRAM OPTIONS

 INPATIENT

Inpatient treatment means twenty-four-hour care in a hospital setting, which can be a medical or psychiatric facility or both. The cost is usually quite high, around $1,200 to $1,400 per day. Inpatient treatment at a strictly medical hospital is usually a short-term stay to treat medical conditions or complications that have arisen as a result of the eating disorder. In some cases, a patient may stay longer simply because her medical condition is severe. In other cases, patients stay longer in a medical hospital than is medically necessary because there is no other facility close by to treat the patient. This is particularly true if the hospital has provisions or a treatment protocol for eating disorders. The rest of the inpatient treatment of eating disorders takes place in psychiatric hospitals that utilize nearby or associated medical facilities when necessary. It is very important that these psychiatric hospitals have trained eating disorder professionals and a treatment program or special protocol for treating eating disorders. Treatment in a hospital without specialized care for eating disorders will not only be unsuccessful but can cause more harm than good.

PARTIAL HOSPITALIZATION OR DAY TREATMENT

Often individuals need a more structured program than outpatient treatment but do not need twenty-four-hour care. Additionally patients who have been in an inpatient program can often step down to a lower level of care but are not ready to return home and begin outpatient treatment. In these cases partial programs or day treatment programs may be indicated. Partial programs come in a variety of forms. Some hospitals offer programs a few days per week, or in the evening, or a few hours each day. Day treatment generally means the person is in the hospital program during the day and returns home in the evening. These programs are becoming more prevalent, in part due to the cost of full inpatient programs and also due to the fact that patients can receive great benefits from these programs without the additional burden or stress of having to leave home entirely. Due to the amount of variation in these programs it is not possible to give a fee range.

RESIDENTIAL FACILITIES

The majority of eating disordered individuals are not medically unstable or actively suicidal and do not require hospitalization. How-ever, a substantial benefit may be received if these individuals can have supervision and treatment on a twenty-four-hour-per-day basis of a different nature than hospitalization. Bingeing, self-induced vomiting, laxative abuse, compulsive exercise, and restricted eating do not necessarily lead to acute medical instability and thus do not qualify by themselves as criteria for hospitalization. If this is the case, many insurance companies will not pay for hospitalization since coverage often requires the individual to be dangerously medically compromised. However, eating disorder behaviors can become so habitual or addictive that trying to reduce or extinguish them on an outpatient basis can seem almost impossible. Residential treatment facilities offer an excellent alternative, providing round-the-clock care in a more relaxed, affordable, nonhospital setting.

Residential facilities vary greatly in the level of care provided, so it is important to investigate each program thoroughly. Some programs offer sophisticated, intensive, and structured treatment very similar to a hospital inpatient program but in a more relaxed environment and in some cases even a renovated house or estate. These facilities often utilize physicians and nurses, but not on a twenty-four-hour-per-day basis, and the residents are referred to as clients, not patients, as they are medically stable, not requiring acute medical care. Other residential facilities are less structured and provide far less treatment, often centered around group therapy. This type of residential program falls somewhere above recovery or halfway houses (see below) but with less structure than the type of residential program described here.

Some individuals go directly to residential treatment programs, while others spend time in an inpatient facility and then transfer to a residential program. Residential treatment is becoming very popular as a choice for treating eating disorders. One reason for this is the cost. Some residential programs charge as little as one-third of the fees of most inpatient facilities. Cost varies but is usually between $400 to $900 per day. Furthermore, residential programs can offer a crucial and important treatment feature not feasible in an inpatient setting. In some (but not all) residential settings, patients have the opportunity to be increasingly involved in meal planning, shopping, cooking, exercise, and other daily living activities in which they will need to participate upon returning home. These are problem areas for eating disordered individuals that cannot be practiced and resolved in a hospital setting. Residential facilities offer treatment and supervision of behaviors and daily living activities, providing clients with increasing responsibility for their own recovery.

HALFWAY OR RECOVERY HOUSE

A halfway or recovery house can easily be confused with residential treatment, and in some cases there is a fine line of distinction between them. Recovery houses have far less structure than most residential programs and are usually not equipped for individuals who are still engaging in symptomatic eating disorder behaviors or other behaviors needing a good deal of supervision. Recovery houses are more like transitional living situations where residents can live with others in recovery, attending group therapy and recovery meetings and participating in individual therapy either as part of the house program or with an outside therapist. The idea was originally developed for drug and alcohol addicts so they could have a place to live with other recovering addicts attending group therapy and/or recovery meetings under the supervision of a "house parent." This was designed to help individuals practice sober living skills before going back to live with their families or on their own. These recovery homes are far less expensive than hospitals and even less than residential facilities. Fees can range from as little as $600 up to $2,500 per month, depending on the services provided. However, it must be kept in mind that most halfway or recovery houses provide far less treatment and supervision than is necessary for many eating disordered individuals. This option seems useful only after a more intensive treatment program has been successfully completed.

WHEN TO USE TWENTY-FOUR-HOUR CARE

It is always the best circumstance when an individual chooses to enter into a treatment program by choice and/or before it becomes a life-or-death situation. A person may decide to seek treatment in a hospital or residential setting in order to get away from the normal daily tasks and distractions and focus exclusively and intensely on recovery. However, it is often as a result of medical evaluation or a crisis situation that the decision to go to, or put a loved one in, a treatment program is made. To avoid panic and confusion, it is important to establish criteria for and goals of any hospitalization ahead of time, in case such a situation arises. It is essential that the therapist, physician, and any other treatment team members agree on hospitalization criteria and work together so that the patient sees a competent, complementary, and consistent treatment team. The criteria and goals should be discussed with the patient and significant others and, when possible, agreed on at the beginning of treatment or at least prior to admission. Involuntary hospitalization should be considered only when the patient's life is in danger.

In relation to the specific eating disorder behaviors, the primary goal of twenty-four-hour care for the severely underweight anorexic is to institute refeeding and weight gain. For the binge eater or bulimic, the primary goal is to establish control over excessive bingeing and/or purging. Hospitalization may be needed to treat coexisting conditions such as depression or severe anxiety that are impairing the individual's ability to function. Furthermore, many eating disordered individuals experience suicidal thoughts and behaviors and need to be hospitalized for protection. A patient may be hospitalized strictly for a medical condition or complication such as dehydration, electrolyte imbalance, fluid retention, or chest pain, in which case a medical hospital may be sufficient. The decision regarding where to hospitalize must be decided on a case-by-case basis. When hospitalization is intended to address any of the eating disorder issues, it is important to look for a treatment program or hospital unit specializing in the care of eating disordered patients. Below are some guidelines as to when a decision to hospitalize might be made.

SUMMARY OF REASONS FOR HOSPITALIZATION

• Postural hypotension (low blood pressure).

• Cardiac dysfunctions such as irregular heartbeat, prolonged QT interval, ventricular ectopy.

• Pulse less than 45 beats/minute (BPM) or greater than 100 BPM (with emaciation).

• Dehydration/electrolyte abnormalities such as a serum potassium level less than 2 milligrams equivalents per liter, fasting blood glucose level less than 50 milligrams per 100 milliliters, creating a level greater than 2 milligrams per 100 milliliters.

• Weight loss of more than 25 percent of ideal body weight or rapid, progressive weight loss (1 to 2 pounds per week) in spite of competent psychotherapy.

• Binge/purge behaviors are happening multiple times per day with no or little reduction.

• Outpatient treatment failure: (a) patient is unable to complete an outpatient trial, for example, can't physically drive to or remember sessions, or (b) treatment has lasted six months with no substantial improvement (e.g., weight gain, reduction of bingeing or purging, etc.).

• Observation for diagnosis and/or medication trial.

• Suicidal thoughts or gestures (e.g., self-cutting).

• Chaotic or abusive family situation, in which the family sabotages treatment.

• Inability to perform activities of daily living.

By  Carolyn Costin, MA, M.Ed., MFCC
- Medical Reference from "The Eating Disorders Sourcebook"

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