Consistently, the research on eating disorders highlights that treatment should be offered in the very least restrictive setting possible to effectively address the condition. [i] The outpatient setting (treatment in one’s real-life environment) is the least restrictive treatment setting available and the best 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.
Among the benefits of treatment in an outpatient setting: patients can remain fully engaged in their lives… attending school, work, involved in family life etc. The outpatient therapy structure can range in intensity from just a simple weekly therapy session to daily therapeutic support – up to 3 hours each day (this would be an Intensive Outpatient Program). The intensity of the treatment depends on a number of factors including but not limited to the severity of the eating difficulties, time frame of the treatment course, and presence of other conditions occurring alongside the eating disorder (like depression or anxiety).
Treating in the context of “real life” makes sense for several important reasons:
- The most researched and effective eating disorder treatments are designed for the outpatient setting
The leading therapy interventions foreating disorders (like Enhanced CBT) were designed specifically for outpatient application. They can be adapted somewhat for Day Programs or Residential settings, but they were created for and tested in the outpatient practice setting.
- It’s helpful for recovery to remain engaged in work/school and to stay connected to family and social supports
While stepping away from life to engage in residential or inpatient treatment may be necessary in some cases, for most people, it’s actually more productive to do the important work of eating disorder therapy while facing the day to day triggers and challenges of life. This way, you can learn how to manage these triggers effectively without resorting to eating disorder behaviors to cope. You become armed with skillls for life that you practice with support until they become second nature. Further, for many, “taking a break” from school/work/family responsibilities simply isn’t possible. 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.
- Outpatient treatment tends to be the most affordable course
Without question, outpatient treatment is the least expensive level of care – approximately 10% of the cost of inpatient.[ii] Since most patients depend on insurance for major medical expenses, “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 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.
The First Step
Arguably one of the most important components of a successful eating disorder treatment is a thorough assessment. In an assessment, the provider collects a full history and will obtain a clear understanding of the current struggles. Prospective Columbus Park patients will complete several diagnostic questionnaires before starting treatment which us get a baseline for symptoms of depression, anxiety and Post Traumatic Stress Disorder. Thorough assessment sets the stage for us to begin the systematic unravelling of the eating disorder. It informs the particular kind of behavioral therapy we will use and the intensity.
Intensive Outpatient Program for Eating Disorders (IOP)
For pateints who require more intensity than standard outpatient but are not necessarily candidates for a setting that might require a leave from work or school life, an Intensive Outpatient Program may be the ideal middle path. An Intensive Outpatient Program (IOP) is a treatment option that serves as a step-down from a residential or partial hospitalization program, or a step-up from standard outpatient therapy. For those who are phasing back into their everyday lives after a residential stay or partial hospitalization program, IOP is an opportunity to restore independence. For those who are seeking a higher level of care than a traditional outpatient program, IOP provides more points of contact with a treatment team and peers while enabling participants to participate in the activities of daily life, as appropriate.
Traditional IOP programs will require between 6-15 hours of treatment per week over the course of 3-5 days. The intensity (i.e. 3 vs 5 days) depends on the individual needs of the client. Some programs run IOP in the evening hours (5-8pm or 6-9pm) while other programs may offer more flexibility with daytime options for those whose schedules allow.
IOP is an opportunity for many to “jump start” treatment. In other words, in a short amount of time, programs work to redirect and shape behaviors, change long-standing patterns and support new strategies for stable eating. Typical expectations for an IOP suggest a 50% reduction in symptoms within 8 weeks. For those who are stepping down from more intensive settings, IOP may be structured differently…. to slowly expose the individual to more and more independence until the client feels confident to move on.
IOP hours typically include group therapy, supported meals, individual therapy and family work (if indicated). Intervention strategies and objectives vary by disorder. For example, for anorexia clients, it’s important to see movement toward more varied and balanced eating along with a clear trajectory of weight restoration. With bulimia, an ideal program will focus in on food exposure, variety and skills for managing/coping with urges to binge or purge. For binge eating disorder, an IOP program would be geared around skill building, developing self-awareness, mindfulness, distress tolerance, and emotion regulation.
To determine if an individual is appropriate for an IOP program, clinics will typically utilize standards established by the American Psychiatric Association. Below is a basic chart – based on the APA standards – that we use at our Columbus Park IOP. It represents some factors we consider when establishing the appropriate level of care for individuals coming into our program.
|Standard Outpatient Criteria||Intensive Outpatient Program Criteria||Partial Hospital/Residential/Inpatient Criteria|
|Medically stable/cleared by Medical Doctor||Medically stable/cleared by MD/ frequent follow up required||Medical instability|
|With guidance, patient is capable of creating one’s own meal structure||External structure needed to eat normally or gain weight||Supervision required during/after meals|
|Fair to good motivation to recover||At least fair motivation to recover||Poor motivation to recover|
|Co-morbidities (i.e. depression, anxiety) may have some limited impact on functioning||Co-morbidities (i.e. depression, anxiety) have high impact on functioning||Psychiatric 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 modulate compulsive exercise||Some ability to modulate compulsive exercise||Structure needed to prevent compulsive exercise|
|Some social support||Limited social support||No support available to add structure outside of treatment|
|Weight: safe range||Weight: significantly compromised range||Weight: severe compromise|
Finding an Intensive Outpatient Program (IOP)
Could you or a loved one benefit from an IOP program? Most insurance carriers list local facilities that are covered in their networks. You can either look on your carrier website or call a representative who can walk you through the covered facilities. It’s also great to search online since most programs will have detailed information on their websites. You’ll want to get a sense of the overall program philosophy, treatments used, structure and schedule. Ask for a tour or informational meeting to get more of a sense of the setting. Be an educated consumer and ask questions. You have a right to know what you’re getting into even before you go in for an initial assessment.
[i] 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.
[ii] Hay P, Chinn D, Forbes D, Madden S, Newton R, Sugenor L, Touyz S, Ward W. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Australian & New Zealand Journal of Psychiatry 2014, Vol. 48 (11) 977–1008