Intensive Outpatient Treatment Program Offers Flexibility, Individual Attention
Treating patients with eating disorders in an intensive outpatient setting offers a number of advantages for patients, families, and staff members alike, according to Dr. David M. Garner, Director of the River Centre Eating Disorders Program in Toledo, OH. Dr. Garner, Julie Desai, and other staff members described their program during a workshop at an annual meeting of the Academy for Eating Disorders.
A major advantage of an intensive outpatient program is the flexibility to design and alter individual treatment. For example, Pamela Orosen-Weine, PhD, Director of Outpatient Services, contrasted the intensive outpatient setting with a hospital-based outpatient program where no workable intensive or hospital program specially designed for people with eating disorders could be developed. When patients with eating disorders had escalating symptoms, little could be done for them except to put them on a general unit. “One of the benefits of working in an intensive outpatient program, “Dr. Orosen-Weine said, is that “it reduces therapists’ anxiety about what to do when a patient’s symptoms are escalating.”
Patients typically spend 7-hour days, 3 to 5 days a week, at River Centre. The small size of the group, usually about 10 to 12 patients at a time, and the staff size, 5 staff members on duty each day, lead to close monitoring and interaction. Patient ages range from adolescents to adults. Adolescent and younger patients stay at home with their parents while adult patients live in nearby apartments or hotels. About two-thirds of the patients live within a 2-hour commute.
The length of stay varies widely. The average stay for anorexia nervosa patients is 5 days a week for 3 months. Some patients become well enough to attend only 3 days a week. Dr. Garner stressed that the intensive day treatment program is a vehicle for achieving therapeutic goals, not simply a 10-week or 15-week, one-size-fits-all program.
In the beginning, the center makes certain that enough time is allowed for a realistic length of participation in the program. If an anorexic patient is to gain an average of 2 lb per week, it would thus take 15 weeks for her to gain 30 lb, for example, plus 2 to 3 weeks after the goal weight is met to give the patient enough time to gain self-confidence, and be able to maintain her weight.
Some individuals in junior high, high school, or college devote full time to their treatment; others may attend school part time during treatment. Some students benefit from attending school because they stay connected to their friends and others in their home environment as well as keeping up with their homework . Some clients are tutored in the evening, after the day’s treatment is over, or on weekends. Some attend school in the morning and come to the Center in the afternoon.
Patients are monitored throughout the day, including in the kitchen and during and after meals. Those who have problems with purging are accompanied to the restroom.
“When patients first come to the center, most are not eating much at all. At that point they are not expected to do their own meal planning because this is too overwhelming to them,” Dr. Garner said. As they get better, patients can chose from 30 to 40 different prepackaged entrees. The staff approaches resistance to meals by asking patients to think of planned mealtimes as an experiment during treatment: just as a splint is used to support a broken bone, structured meals are necessary, for a time, to help normalize eating.
When patients first enter the program, the goal is to get them to eat all their daily calories in a 7-hr. period. As they get better, this moves toward a more natural way of eating. When patients first enter the program, they may receive a “prescription” for 1500 kcal/day, for example. While this might seem mind-boggling to them since they have often been eating only 400 kcal/day, Dr. Garner has found that it rarely takes more than 2 days to get patients up to eating approximately 2000 kcal per day.
Body weight is only one part of the equation for recovery, and when weight goals are calculated, the staff uses a target weight that they estimate will allow the patient to begin to menstruate. They stress that weight should be a healthy weight, defined as a weight that the patient can maintain biologically without a great deal of dieting. Goal weights often have to be approached in stages, such as using positive ways of framing the need for additional calories, stressing the importance of improving metabolic function, and “bathing the brain with nutrients.” The emphasis is on improving health and increasing strength. “The goal weight is nonnegotiable if recovery is the goal,” says Dr. Garner.
Calories are also presented as medication; that is, the patient is told that if the amount of prescribed food is producing too great a weight gain (above 3 lb per week, for example), the “dosage” will be cut. “Our program’s emphasis is on proper control of eating and weight gain, as opposed to programs that attempt to pack on as many pounds as possible per week,” Dr. Garner remarked.
Weight gain is not the only criterion for discharge. In fact, Dr. Garner said, “We are very clear about communicating that weight gain is a minimal standard—a necessary but insufficient standard for recovery.” In other settings, patients may feel that once they gain the requisite weight they won’t be able to get the psychological help they need, and may therefore become even more resistant to gaining weight.
Dr. Garner noted that family therapy takes many forms at the center. He said there is conceptual harmony between cognitive behavioral therapy and family therapy, and staff members and families work on themes of over-protectiveness, enmeshment, and poor conflict resolution. Parenting skills are also taught, “The hallmark of our program relates to flexibility in the integration of principles of interpersonal and family therapy as well as cognitive behavioral therapy.”
Group meetings take many forms—for example, at one time, when the center was treating 4 or 5 very young patients, they arranged morning meetings with all of the families because the themes applied to all. The parents shared their concerns. This process was very effective because parents felt they were not alone with their problems and also felt they weren’t being “picked upon” or singled out for blame because the other parents had the same concerns and issues.
For individuals, meetings are purposely kept short—usually no longer than 10 to 15 minutes. This is possible because of the intensive treatment setting, Dr. Garner explained, adding, “You don’t have to collect a whole week of background information when you have seen the person the day before or when they have been in a group. We can really get right to the heart of the subject and address the issues that interfere with treatment and other issues that need to be addressed.”
Frequent staff conferences, sometimes 3 to 4 a day, help prevent and minimize frustrations, spitting, burnout, and excessive negative countertransference. These meetings also help intercept little problems before they escalate. “We are very up front with patients about our concerns,” Dr. Garner said, “and we talk with them and each other in group meetings about staff concerns and hidden agendas.”
The staff keeps close telephone contact with parents. If parents are having problems, they are encouraged to telephone immediately rather than waiting for the next weekday or waiting over a weekend, so that progress made during the week can be enhanced, supported, or even salvaged.
Aftercare continues with ongoing therapy for as long as necessary. In many cases, referrals to local therapists are made.
The treatment program at River Centre provides a good model of an intensive outpatient program. It is not unique in its design or existense. Other similar programs have been insituted by therapy groups and treatment facilities in many communitites. Potential patients and their families can use the River Centre example as a starting point when discussing therapy options with their local providers.
Reprinted with permission from Eating Disorders Recovery Today
Spring 2003 Volume 1, Number 4
©2003 Gürze Books
Mary K. Stein, Managing Editor, contributed to this article, a version of which first appeared in the Eating Disorders Review.