Levels of Care: Choosing the Right Eating Disorder Treatment

Levels of Care in Eating Disorder Treatment

If you’re struggling with an eating disorder and have started to research treatment, chances are you’ve come across different types of therapies in different formats and locations. You might have noticed that a number of professionals are involved in eating disorder treatment (e.g., psychotherapist, registered dietitian, medical doctor, perhaps other specialists too).  You might have even come across the term, “levels of care.”

How do you know the right option for you?

Defining Levels of Care

Below is a list of the typical levels of care for an eating disorder, from least to most intensive:

• Outpatient treatment: Outpatient treatment is what we reference when discussing therapy, meetings with a dietitian, or other services that are 1-on-1 (or group) and only require a couple of hours a week investment. Outpatient services occur in an office setting (or online).
• Intensive outpatient treatment (IOP): IOP typically includes several hours of therapy a couple of days a week or more.  Programming generally includes group therapy, one meal or snack per visit, and access to individual providers. Clients who attend IOP receive more therapy (and peer support) than those in standard outpatient treatment but are still generally able to invest most of their time in other arenas (e.g., work/school, family, etc.). IOP programs might be housed at private practices, community health centers, hospitals, residential treatment facilities, etc. Newer programs have also popped up online.
• Partial hospitalization (PHP): PHP is a hybrid between IOP and residential treatment. PHP provides daily programming (generally 5-7 days/week) for the bulk of the day. However, clients don’t reside at the center; they return home each night. In PHP, clients will eat most of their meals and snacks as part of the treatment schedule, but they will be on their own with food at times, either on their “off” days, at nights for snack, at times for breakfast, etc. PHP programs are typically housed at hospitals and residential treatment facilities, though again, are sometimes now offered online.
• Residential treatment (RTC): RTC provides access to round-the-clock care. As the name implies, clients reside at the center 24 hours/7 days a week. RTC is appropriate for those who are medically stable but require more treatment and supervision than less intensive levels of care. RTC may also be appropriate for those with significant co-occurring conditions (e.g., mood disorders, suicidality, substance use disorders, PTSD), requiring more constant supervision. Residential facilities are their own physical establishment, typically a large, homey building with group rooms, offices, living and dining areas, as well as sleeping quarters.
• Inpatient Treatment (IP): IP, also known as medical stabilization, is appropriate for individuals who are medically unstable. They receive 24-hour care in a hospital stetting. Patients may require significant medical intervention, including ongoing monitoring of vital signs, administration of intravenous fluids or feeding tubes, or any other medical management that is unavailable at less intense levels of care, including residential.

Another type of treatment, Family-Based Treatment (FBT), occurs in an outpatient setting but involves significant monitoring/supervision of meals by the client’s family. In this case, the family becomes part of the treatment team, providing intense supervision and care. The client is spared a residential stay and remains with their family, with supervision akin to that in residential treatment.

Choosing the Most Effective Treatment

How do you decide which option is right for you? Most people enter treatment at an outpatient level of care. They might start with a medical doctor, psychotherapist, or registered dietitian, adding members to their treatment team in order to ensure all aspects of their care are addressed. If clients do not experience reduced symptoms with outpatient care, they and/or their team might consider a higher level of care. But what?

Thankfully, the American Psychiatric Association has come up with treatment guidelines for those diagnosed with eating disorders. In determining the appropriate level of care, the APA guidelines consider: medical status, weight, co-occurring disorders (such as substance misuse, PTSD, depression, etc.), safety, motivation for recovery, the structure required for recovery, the ability to control eating disorder behaviors (e.g., purging, exercise), environmental stress, and geographic availability. Notably, these guidelines were written in 2010 and require updating. Moreover, they do not approach the treatment of Binge Eating Disorder (BED, the most common eating disorder but not yet a standalone disorder in 2010) from a weight-inclusive lens, which has been shown to be the most effective approach for addressing BED.

How can you decide? Generally, we recommend the least restrictive/intensive treatment to manage the symptoms present. There are several dimensions to consider when deciding on a level of care that might work for you:

1. How much help/support you need: Ultimately, levels of care vary based on supervision/support and independence. How much supervision/support do you need in order to manage your symptoms? If you do require more intensive treatment, what will you do after the fact? Often, when clients leave the “bubble” of intensive treatment and return to their lives, the drop-off in care is tough. Clients might relapse if adequate supports are not in place. This doesn’t mean residential treatment can’t be beneficial; it can. But it’s important to be thinking of aftercare as soon as possible. It’s also true that some clients might opt for a lower level of care to see if they can manage treatment without having to pause or uproot other aspects of their lives. They might prefer greater independence or value the ability to recover while in their home environments. If this proves difficult, a higher level of care might be helpful as a springboard for ongoing recovery.

2. What type of resources you have: Sadly, eating disorder treatment is largely governed by managed care. While you might benefit from residential treatment, your insurance company might believe you “only” need IOP. Sometimes, insurance will authorize treatment but only for a short period of time, just scratching the surface on what you need. If you don’t have the funds to pay for treatment out-of-pocket, you might be stuck with care that isn’t as intensive as you need.

3. Life demands: Obviously, if your medical status is compromised or your life is otherwise in danger, a higher level of care is warranted regardless of life demands. The same can be said when lower levels of care have proven ineffective. But it might also be true that someone who can’t leave their job or can’t leave young children at home might try a lower level of care before they are willing to consider residential. Eating disorders don’t occur in a vacuum, and it’s important to consider life demands in making this decision.

At Gatewell, we offer outpatient psychotherapy and nutrition services for eating disorders in a setting that values individuality and diversity. Clients are generally seen 2-3 times a week and can participate in group therapy for additional support. Additionally, we offer meal support services, so that clients don’t have to complete their meals alone; they can do so with our guidance and support. In this way, clients at Gatewell can create an outpatient program that approximates an IOP, offering multiple services and modalities per week. And yet, sometimes this isn’t enough. As seasoned eating disorder specialists who have worked at multiple levels of care, we know how and when to spot the need for more intense treatment and are able to offer our clients appropriate referrals, guidance, and problem-solving to get the care they need.