For some people entering the eating disorder world, they may hear the words “higher level of care” and wonder what that means and how it may apply to them or their loved one. This is intended to break down the different levels and why they can be helpful.
Generally speaking, higher levels of care refer to treatment centers that offer more than outpatient therapy. Different programs offer different levels and have different treatment models, so it can be helpful to understand the specifics when making a decision about what program would be a best fit for you.
Professionals recommend higher levels of care for several reasons:
- The client is medically unstable (abnormal labs or EKG, orthostasis, rapid weight loss, etc.)
- The client needs frequent and professional meal support
- Comorbid issues need to be addressed with wrap-around care that is more intensive than what outpatient can provide
- The intensive group therapy component could be beneficial for the client in order to stimulate therapeutic growth
These different reasons usually help indicate which level of care would be most helpful. I’m going to work my way up from outpatient and give descriptions of each level.
This is “regular therapy” – when a client sees a therapist weekly and often a dietitian weekly or biweekly as well. Empowering You LLC is an outpatient provider. Clients are able to complete meals consistently, develop insights in therapy, complete challenges from nutrition sessions, and often engage in life without the eating disorder causing too many disruptions. Sometimes clients start here and stay here; sometimes they start here but are recommended for a step-up to a higher level of care; sometimes they step down to outpatient after completing treatment.
In order to attend a program, a client completes an assessment with one of their clinicians who decides what level of care would be most appropriate. This is based on the information gathered from the client, parents or supports, and the outpatient team (if applicable). They also work with insurance to complete pre-authorizations and will explain the cost and insurance benefits before starting.
Intensive Outpatient (IOP)
Some programs offer both IOP and PHP in the same facility, with IOP being the lower level of care. It usually consists of a few days or nights per week for several hours each day (for example, 3 hours in program for 3 days per week, for a total of 9 hours). Usually, each program day consists of one meal and a couple of groups and provides you with a dietitian on site, as well as a check-in with a therapist on staff, thus allowing you to keep your outpatient therapist if you already have one. The benefit of this is that you either start building rapport with a new outpatient therapist, or you continue to work with your old one, in an effort to make the step down to “real life” and outpatient more manageable. People who are usually appropriate for IOP may be feeling stuck in outpatient and would really benefit from the supported meal and group component. Although symptom use is still present, these behaviors do not get in the way of work, school, or relationships to a significant degree. Sometimes, people are assessed for IOP immediately, while other times people step down from PHP to IOP before discharging to outpatient. Stays in IOP are usually around 6-8 weeks, but this can depend on the client.
Partial Hospitalization Program / Day Treatment (PHP)
PHP is more intensive than IOP and usually involves some sacrifices when it comes to work and school. Depending on which facility you choose, PHP can run from 5-6 hours for 5 days per week, to 7-10 hours 7 days per week. Now, while this may sound like a lot of treatment – and, realistically, a huge inconvenience too – PHP is truly a game-changer when it comes to recovery. Clients receive 2-3 meals (and sometimes snacks) in treatment every day, which is supervised by a therapist or dietitian. It allows for the supervision of meals, the challenging of fear foods in a therapeutic setting, extra accountability for meal completion and the decreasing of food rules and rituals. This takes a lot of pressure off families, as they will not have to make or monitor meals for most of the week. PHP also includes individual therapy (so clients no longer see their outpatient therapist), family therapy if applicable, weekly dietitian appointments, and an on-site psychiatrist. Having all of these providers under one roof is highly beneficial from a treatment perspective, as they can easily collaborate and make changes rather quickly, whether that be to a meal plan or medications. These appointments and meals are interspersed with groups throughout the day that teach distress tolerance skills, focus on connection, and help clients with body image, among other topics. Some programs also have tracks for substance abuse, trauma, or different religions. Clients who are appropriate for PHP heavily use symptoms, which is causing interference in daily life, or are struggling to complete meals or decrease symptom use at the outpatient level. Symptoms are present daily and motivation to change is often lower than clients who are appropriate for IOP. If clients continue to struggle in PHP, they are stepped up to residential treatment. Stays in PHP typically last 4-6 weeks, although this depends on the client.
Residential Treatment Centers (RTC)
Residential, or “res,” is exactly what it sounds like – a facility where clients reside 24/7 for intensive therapeutic, psychiatric, and nutritional care. Residential facilities also have a full medical staff so that the medical side of the eating disorder can be monitored regularly, on top of having group, individual, and family therapy, dietitian sessions, and a psychiatrist. While residential might sound scary, for some people, being removed from the stressors of daily life while they regulate their nutritional intake and receive intense therapy is exactly what they need to start their recovery journey. Programs often separate adolescents from adults, and typically have a family component – regardless of age – to help support parents, spouses, and loved ones navigate recovery. Clients who are appropriate for residential treatment do not typically have much motivation to recover but are experiencing the physical side effects of malnutrition and sometimes are unable to develop insight into their eating disorder because of this. Some residential facilities have the ability to provide tube feeding if clients are not eating, but they also have contacts at local hospitals if clients need to step up to an inpatient unit. Stays in residential are often around a month, but this depends not only on the client but insurance as well.
Inpatient is the highest level of care offered for eating disorders, although most people do not experience this in their eating disorder journey. Inpatient is not therapeutic and purely exists to mitigate the negative physical effects of an eating disorder. Clients do not typically receive much, if any, therapy, as they are usually too compromised to engage in it. They are put on a feeding tube upon arrival and are often tube fed overnight, on top of their daily meals that they are offered. If clients do not complete their meals, they are offered a supplement (Ensure, Boost, etc.). If they do not complete those, they receive their meals through their tube. Clients who end up in the hospital are medically unstable, which usually occurs after an irregular EKG shows a dangerously low heart rate. The tube feeding on top of their regular meals is required due to them being hypermetabolic – their digestive system is metabolizing food so fast that they need extra calories to ensure they can gain weight – and allows their heartbeat to regulate as the body is properly nourished. Stays are typically around a week, and the unit usually helps clients find a residential site to step down to afterward.
While higher levels of care sound intimidating, they truly can help accelerate the recovery process in a way that outpatient cannot accomplish quickly. In the next blog, you can look at questions to ask treatment centers when they are completing the assessment so that you feel like you are informed before making any decisions.