• What is the overall philosophy of treatment, including the program's position on psychological, behavioral, and addictive approaches? ?

• How are meals handled? Is vegetarianism allowed? What happens if the meal plan isn't followed?

• Is there an exercise component other than walks or recreational activities?

• How many patients have been treated and/or are some available to speak with you?

• What kind of background and qualifications do staff members have? Are any or many recovered?

• What is the patient schedule (e.g., how many and what kind of groups are held daily, how much leisure time is there? how much supervision versus treatment takes place)?

• What step-down levels of care are provided, and what are the arrangements for individual therapy? Who performs it and how often?

• What are the outpatient or aftercare treatment and follow-up services? What is considered noncompliance, and what are the consequences?

• What is considered to be the average length of stay and why?

• What are the fees? Are there any extra fees besides those quoted that may occur? How are fees and payments arranged?

• What books or literature are given or recommended?

• Is it possible to meet with a staff member, visit a group, or talk to current patients?

Since different patients will be looking for different things in a treatment program, providing the "right" answers to the above questions is not possible. Individuals considering a treatment program for themselves or a loved one should ask the questions and get as much information as they can from various programs in order to compare options and select which program is most suitable.

The following information on Monte Nido, my residential program in Malibu, California, provides an idea of the philosophy, treatment goals, and schedule of a twenty-four-hour care facility specializing exclusively in anorexia nervosa, bulimia nervosa, and activity disorders.

MONTE NIDO TREATMENT CENTER

PROGRAM OVERVIEW

Eating disorders are progressive and debilitating illnesses requiring medical, nutritional, and psychological intervention. Individuals suffering from eating disorders often need a structured environment to achieve recovery. However, all too often a person does well in a highly structured, regimented environment only to fall into relapse upon returning to a less structured situation. Our residential program is designed to meet the individual needs of clients and their families in a way that gives them a higher level of responsibility and "teaches" them how to recover. The atmosphere at Monte Nido is professional and structured, but it is also warm, friendly, and family like. Our dedicated staff, many of whom are recovered themselves, serve as role models, and our environment inspires people to commit to overcoming obstacles that are interfering with the quality of their lives.

The program at Monte Nido is designed to provide behavior and mood stabilization, creating a climate where destructive behaviors can be interrupted. Clients can then work on the crucial underlying issues that caused and/or perpetuate their disordered eating and other dysfunctional behaviors. We provide a structured schedule with education, psychodynamic, and cognitive behavioral therapy; corrective eating patterns; healthy exercise; life skills training; and spiritual enhancement, all in our beautiful, serene country setting.

Our treatment philosophy includes restoring biochemical functioning and nutritional balance, implementing healthy eating and exercise habits, changing destructive behaviors, and gaining insight and coping skills for underlying emotional and psychological issues. We believe that eating disorders are illnesses which, when treated correctly, can result in full recovery where the individual can resume a normal, healthy relationship to food.

Nutrition and exercise are not simply a part of our program. We recognize these as crucial areas of recovery. Therefore, we require assessments on nutritional status, metabolism, and biochemistry, and we teach patients what this information means in terms of their recovery. Our exercise physiologist and fitness trainer perform thorough assessments and develop a fitness plan suitable for each client's needs. Our detailed attention to the nutrition and exercise component of treatment reveals our dedication to these areas as part of a plan for a healthy, lasting recovery.

Every aspect of our program is designed to provide clients with a lifestyle they can continue on discharge. Along with traditional therapy and treatment modalities, we deal directly and specifically with eating and exercise activities that can't be adequately addressed in other settings but, nevertheless, are crucial for full recovery.

Planning, shopping, and cooking meals are all part of each client's program. Dealing with these activities is necessary since they will have to be faced on returning home.

Clients participate in exercise according to individual needs and goals. Exercise compulsion and resistance are addressed with the focus on developing healthy, noncompulsive, lifelong exercise habits. We are uniquely set up to meet the needs of athletes who require specialized attention in this area.

Activities include weight training, water aerobics, yoga, hiking, dance, and rehabilitation for sports injuries.

Individual and group therapy establish and solidify the other treatment components. Through intensive individual sessions and group work, clients gain support, insight into their problems, and the ability to transform them. Increasing confidence is gained in appropriately selecting meals and exercise activities, while using other methods to deal with underlying issues. Outings and passes are provided to assess each client's growth in handling real-life situations. On returning from an outing or pass, clients process their experience in both individual and group sessions in order to learn from it and plan for the future.

Group topics include:

• Cognitive-Behavioral Therapy

• Communication Skills

• Self-esteem

• Stress/Anger Management

• Body Image, Women's Issues

• Art Therapy

• Assertiveness Family

• Therapy

• Sexuality and Abuse

• Life Skills

• Career Planning

We are innovative and unique. Our director, Carolyn Costin, M.A., M.Ed., M.F.C.C., recovered herself for more than twenty years, has many years of experience as a specialist in the field of eating disorders. Her extensive expertise, including a directorship of five previous inpatient eating disorder programs, combined with her unique, hands-on empathetic approach, has achieved high success rates with full recovery. Carolyn and our staff can empathize, offer hope, and serve as role models while providing skills for recovery.

LEVEL SYSTEM

Our level system allows for increased freedom and responsibility as clients progress in the program. All clients have a written contract which they help create. The contract shows the current level they are on and spells out the goals for that level. Each client's program is individualized even though there are certain activities, reading assignments, and other requirements for every level. A copy of the contract is given to each client, and one is kept in the client's chart.

Special privileges. If deemed appropriate, clients may have special privileges in their contract that allow for things not usually spelled out on the level they are on.

Level changes. When clients feel they are ready, they can request to move to the next level. Level changes and decisions are discussed in individual sessions and the contract group. Clients must request at the beginning of the group for time to discuss their level-change request. Clients will receive feedback from the staff and peers in the group. The matter is taken by the group leader to the treatment team for a final decision. The client will then be told that same day or the next day whether the level change was approved.

Down leveling. Occasionally clients are moved up to a level and find that it is too difficult to accomplish the tasks on that level. Clients may be down leveled to an appropriate level with more structure until they are ready to try again.

Weight. Unless otherwise contracted, weight is taken and recorded once weekly with bulimics and twice weekly with anorexics, with the client's back to the scale. Only the therapist, the clinical director, or dietitian may tell the client her weight or any changes in weight.

Mealtimes and place. Clients will be asked not to go to the kitchen or begin any meal preparation until scheduled meal or snack time and not without staff present until they are on Level IV or Level III by contract. Clients are to eat meals in the dining room or other area supervised by staff until Level IV.

Snacks. Snacks will be served two or three times per day according to client needs. Protocol for snacks is the same as meals, according to the client's level and contract.

ENTRY LEVEL

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The first phase in our level system is the Entry Level. Entry Level begins with the client's admission into the facility and continues until the first contract is made. During this time clients are getting acquainted with our program and will be given an Entry Level contract that lists certain tasks to be accomplished. Assessments will begin right away, and the treatment team will be getting to know the client. During Entry Level, clients are on a "grace" period with no formal requirements for eating. This gives us time to know the client and what her needs will be. In some cases an initial calorie assignment may be made. During Entry Level, clients will attend meals with other clients and a staff member, but no formal eating requirement is made. Entry Level lasts no more than three days. After Entry Level, the client helps develop her first contract on Level I and then continues on through the level system. An example of our Entry Level contract is provided along with our program schedule on pages 273 and 274 at the end of this chapter.

PHASES OF TREATMENT

• Initial interview, clinical assessment

• Comprehensive history and physical by our or your medical doctor

• Admission and orientation to the program

• Comprehensive psychological assessments, including a psychiatric evaluation

• Nutrition/exercise assessments and initial meal and exercise plan established

• Treatment team establishes a treatment plan

• Active involvement begins in therapy, education, activities, and family sessions

• Client works through the level system, gaining understanding, control, and confidence, and establishes a lifelong plan for recovery and wellness

• Staff helps client to make transition through the level system, providing increasing responsibility for self-care

• Treatment team, with client, reevaluates discharge criteria and discharge date

• Discharge with plan for transitional living or other aftercare

TREATMENT COMPONENTS

• Individual, Group, and Family Therapy (Cognitive Behavioral and Psychodynamic Therapies)

• Psychiatric Evaluation and Treatment

• Medical Monitoring

• Communication and Life Skills Training

• Meal Planning, Shopping, and Cooking

• Nutrition Education and Counseling

• Exercise, Fitness, and Rehabilitation Program

• Art Therapy and Other Experiential Therapies

• Occupational, Career Planning

• Biochemical, Nutritional Stabilization

• Body Image Treatment

• Sexuality, Relationships, Co-Dependency

• Recreation and Relaxation

• Education Groups—Topics include: stress, psychological development, self-esteem, compulsive behaviors, sexual abuse, spirituality, anger, assertiveness, relapse, shame, women's issues

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