Eating Disorder Treatment: The Least Restrictive Setting

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By, Melissa Gerson, LCSW

In a 2016 exhaustive review of the research on eating disorders there was a consistent finding across all diagnoses (anorexia, bulimia and binge eating):

“Treatment should be offered in the setting that is least restrictive and best suited to the individual’s needs and preferences.”[i]

The outpatient setting (treatment in your real life environment) is the least restrictive treatment setting and the ideal course for the majority of patients. More intensive, highly controlled settings are necessary primarily if there are immediate medical complications or co-occurring issues like suicidality that require a high level of oversight and intervention.

If you think about it, treating in a “real life” setting makes sense:  

  1. The Leading Evidence-Based Treatments Are Designed for Outpatient

The gold standard treatments for eating disorders are designed for outpatient application. They can be adapted somewhat for Day Programs or Residential settings, but they were designed for and tested in the outpatient practice setting.

  1. Work, School, Family Obligations

For most people, participation in work, school or family/social life is an important factor and “taking a break” from these responsibilities for treatment may be impossible. Outpatient treatment reduces disruption dramatically; in outpatient, you’re encouraged to engage, particularly in activities and pursuits that enrich your life, breed a sense of efficacy and boost self-esteem.

  1. Opportunity to Address Stressors Head On

While it’s not easy, working through treatment in the context of daily life challenges allows you to fully address them – with support – and gives you the opportunity to practice new, more effective ways of coping.

  1. Cost

Outpatient treatment is the most affordable level of care. It is said to be approximately 10% of the cost of inpatient.[ii] Since most of us rely on insurance for major medical expenses, the “higher levels of care” like Residential, Partial Hospital and Day Treatment, may be out of the question; insurance companies are becoming increasingly reticent to cover these higher levels care and if they do, the treatment stays are shorter than ever. Unless there is immediate medical risk, most managed care companies require that patients receive an outpatient trial of treatment first.

What’s Right For You

There are certainly situations where a highly structured and restricted setting is necessary but it is important not to jump the gun and assume that this kind of intensity is needed. There are short-term, time-limited outpatient treatments that are effective even for the more severe eating disorders. For example, using CBT-E, patients with severe bulimia can see full results in 20 sessions. And MOST of the change actually happens in the first 8 weeks. In fact, early change is the single most potent predictor of a good outcome.

Inpatient vs. Outpatient Criteria

The first step is a thorough assessment with a provider who is committed to using the research to guide practice. A recommendation will then be made for you based on very specific criteria.

At Columbus Park, we have clear criteria based on guidelines established by the American Psychiatric Association. Below is a sneak peak at the chart that our team uses to establish the proper level of care for those seeking our guidance:

 

Standard Outpatient CriteriaIntensive Outpatient Program CriteriaPartial Hospital/Residential/Inpatient Criteria
Medically stable/cleared by Medical DoctorMedically stable/cleared by MD/ frequent follow up requiredMedical instability
With guidance, pt is capable of creating one’s own meal structureExternal structure needed to eat or gain weightSupervision required during/after meals
Fair to good motivation to recoverAt least fair motivation to recoverPoor motivation to recover
Co-morbidities (i.e. depression, anxiety) may have some limited impact on functioningCo-morbidities (i.e. depression, anxiety) have high impact on functioningPsychiatric condition requiring hospitalization
Suicidality, if present, is passive (no active plan or intent to take one’s life) 

Suicidality, if present, is active and more structure/points of contact needed. Possible suicide attempts in past.

 

Suicidality is active w/intent and plan and unable to contract for safety
Some ability to control exerciseSome ability to modulate exerciseStructure needed to prevent compulsive exercise
Some social supportLimited social supportNo support available to add structure outside of treatment

[i] Hay P, Chinn D, Forbes D, Madden S, Newton R, Sugenor L, Touyz S, Ward W. Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(11) 977–1008

 

[ii] Katzman DK, Golden NH, Neumark-Sztainer D, et al. (2000) From prevention to prognosis: Clinical research update on adolescent eating disorders. Pediatric Research 47: 709–712.


About the Author: Melissa Gerson, LCSW is the Founder and Clinical Director of Columbus Park, Manhattan’s leading outpatient center for the treatment of eating disorders. As a comprehensive outpatient resource for individuals of all ages, they offer individual therapy, targeted groups, daily supported meals and an Intensive Outpatient Program (IOP). Columbus Park uses the most effective, evidence-based treatments like Enhanced CBT and Dialectical Behavior Therapy (DBT) to treat binge eating, emotional eating, bulimia, anorexia and other food or weight-related struggles. They track patient outcomes closely so they can speak concretely about their success in guiding our patients to recovery.

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