Levels of Care in Eating Disorder Treatment

Being diagnosed with an eating disorder or realizing that you are experiencing symptoms of an eating disorder, whether that is anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant restrictive food intake disorder (ARFID) or any combination of these illnesses, can be scary. You may be asking yourself “What do I do?” or “Where should I go for treatment?”. You may even begin to research your options online. The world of online research can become even more daunting because you realize there are different types of care settings for eating disorder treatment. 

Navigating the Levels of Care in Eating Disorder Treatment

You are not alone in the idea that this process is scary. I’m writing this blog to allow for some brief understanding of the levels of care or even shed some guidance on what level of care might work best for you. Just like eating disorder symptoms and severity exist on a spectrum of severity, the treatment options also known as Levels of Care (LOC) also exist on a spectrum of severity. The Levels of care outlined below are organized from lower on the continuum of care and higher on the continuum of care. Eating disorder treatment tends to work best on a continuum of care. 

What this means is that treatment exists on a spectrum depending upon each unique person’s needs. A person can enter this continuum of care at any level of care deemed appropriate after an initial assessment outlining a person’s symptoms and needs. The continuum of care and levels of care system is also set up so that at any time an individual can “step up” or “step down” when needed. 

These levels of care allow for natural step downs when a client has learned skills that help both their mental and physical health and they have learned more autonomy, therefore not requiring as much support. However, sometimes during treatment, as clients begin to feel their emotions, a client may feel they need more support to stabilize eating patterns and decrease eating disorder symptoms. For this reason, a client can always step up in the levels of care for more support when needed. 

Each level of care for eating disorder treatment includes a multidisciplinary team, although the frequency may differ. A multidisciplinary treatment team may include a therapist, dietitian, psychiatrist, medical providers, and/or any other medical professionals. Higher levels of care will likely increase the frequencies of these services as well as the amount of support for both medical and psychiatric stability. You will notice that the levels of care takes into consideration a person’s physical/medical health as well as their mental/psychiatric health. 

What Criteria is Used to Determine Level of Care for Eating Disorders?

The American Psychiatric Association has created guidelines for symptoms and client experiences that need to be taken into consideration when determining level of care. Although an important medical stability indicator, weight is not the only criteria in deciding level of care upon assessment. Treatment facilities as well as insurance companies also may have their own criteria for levels of care. 

The criteria outlined by the APA include the following:

1. Medical status and the need for medical stabilization. Eating Disorders can cause several medical abnormalities that need to be stabilized to lead to overall wellness and psychiatric stabilization. 
2. Weight. Again, this is not the only determinate when deciding level of care. Many individuals can have a normal body weight, while dealing with very severe and enduring eating disorders. Many assessments will consider not only an individual’s percentage of healthy body weight when determining a level of care assessment, but will also look at weight suppression and any weight lost during an individual’s time when dealing with an eating disorder. 
3. Motivation for Recovery. As a clinician that works with eating disorders, it is important to consider that motivation generally ebbs and flows. I frequently consider an individual’s willingness and skill level when recovering. Sometimes an eating disorder can be so severe that it wreaks havoc on an individual’s own motivation to recovery, which may need to be developed and/or created in a higher level of care. 
4. Suicidality and Self-Harming behaviors. The frequency of these thoughts, behaviors, and willingness to contract for safety will determine the level of care and need for supervision. 
5. Any Co-occurring Disorders that Need Stabilization. These co-occurring disorders may include any mood disorders such as anxiety, depression, or bipolar disorder. Other co-occurring disorders may include substance use disorders or even trauma disorders, such as post traumatic stress disorder (PTSD). Higher levels of care can help with medication management around all of these disorders, which can overall lead to a decrease in overall eating disorder behaviors. 
6. The Need for Structure or Surveillance to help improve Eating Disorder Symptoms. This may include surveillance in order to meet certain goals such as a decrease in purging behaviors, increase in eating daily meals, weight goals, or even taking medications as prescribed.  
7. The Ability to Control Compulsive Exercise. Some individuals are not able to disrupt compulsive exercise behaviors, leading to the need for a higher level of care with more surveillance. 

What Are The Levels of Care for Eating Disorders Treatment?

Outpatient Care

Outpatient care ideal when an individual is able to live at home and attend either school or work full time. The client does not experience significant impairment in functioning in terms of work, school and/or daily life. An individual sees a multidisciplinary team of a therapist, dietitian, medical doctor, psychiatrist and/or other professionals at a frequency that is recommended by each team member.

These team members keep in close contact to help the client reach their goals. At this level of care, a client has developed some personal motivations for recovery and, generally, has a willingness to recover.  They have also developed some resources, relationships, and coping skills that they are able to integrate into their recovery process. Although a client may still be experiencing emotional distress in outpatient, they are able to appropriately meet some of their goals set by their multidisciplinary team. 

 

Some typical goals that a client may be working on in outpatient services may include, but are not limited to:

• Working on a relapse prevention plan to help the client in long term eating disorder recovery.
• Working on continued stabilization of eating disorder behaviors through an emotional and behavioral plan.
• Continuance of eating an appropriate meal plan as set by the dietitian.
• Working on integrating fear foods into treatment.
• Working on emotional goals around mood disorders or trauma/attachment disorders.
• Exploring body image distress or body checking behaviors.
• Continuance of care to make sure that the client remains medically stable. 

Intensive Outpatient Programs (IOP)

Some clients may require an intensive outpatient program for long term success in meeting their goals around their mood and eating disorder. Intensive outpatient programs or IOP programs are programs in which a client will attend programming two to three days a week. Generally, programming on days clients attend are for three hours at a time. Clients receive meal support with one meal on each day of programming.  Clients will meet on site with a team of professionals, which includes at least a therapist and dietitian.  At times, a client may still meet with their outpatient therapist. In addition, the client is expected to continue doing their daily life activities, such as work and schooling. They are expected to be medically stable, although weights and vitals will be checked on a weekly basis. 

IOP programs can be a great way for clients to receive more support on developing a meal plan that works for them.  It also aids in developing education to disrupt eating disorder behaviors. Clients will attend groups focused on developing emotional skills, coping skills, and creating an understanding of how their emotions and their eating disorder are linked. Overall, clients remain functional in their daily life activities, but require more support in implementing skills for overall stabilization. I’ve found IOP can also be great for clients that feel they need more help making connections between their emotions and eating disorder behaviors. Generally those in IOP have a good willingness to recover, but may need help in developing their skill set. 

Some typical goals of clients attending IOP programs may include, but are not limited to:

• Creating connections with other individuals that “get” the eating disorder.
• Learning ways to tell support systems about their eating disorder and ways they can help them in their treatment process. 
• Developing a toolbox of coping skills to help disrupt eating disorder behaviors.
• Although successful at some meals, these clients may need help in creating consistency within their meal plan.
• Develop an idea of what emotions may play a role in their eating disorder behaviors.

Partial Hospitalization Programs (PHP) or Day Treatment Programs

Partial Hospitalization programs (PHP) are also known as day treatment programs (DTP). PHP programs are a bit more intense, because at this point the eating disorder is impairing the functioning of the individual at school and work.

Clients may also struggle to implement a daily meal plan and struggle with completing meals. The eating disorder can wreak havoc on personal relationships as an individual may struggle at disrupting their compulsive exercise, purging, restriction, and/or binging behaviors. Overall, the individual may notice their personal motivation for recovery tends to feel like a see-saw. depending on the day and their mood. 

At PHP programs, clients attend treatment anywhere from five to seven days a week for anywhere from six to eight hours depending upon the program. Clients eat two meals at the program and they are offered support. PHP also gives the client more support via weekly therapy, dietitian, psychiatry, family therapy, etc. with a multidisciplinary team. Clients receive daily emotional support and planning around how to meet their goals at home.

Usually, clients have appropriate support at home that is integrated in treatment so that clients can be successful with their meal plan and other emotional goals at home or on weekends. Both PHP and IOP offer time to practice skills and lead to greater autonomy when appropriate. Although medically stable, the client receives weight and vital checks throughout the week. 

Some typical goals of clients attending IOP programs may include, but are not limited to:

• Developing an appropriate behavioral and emotional plan to disrupt eating disorder symptoms in the evening and on weekends. 
• Eat meal plans 100% both in PHP and at home. 
• Learn several meals that they can replicate at home for breakfast, lunch, and dinner.
• Weight restore when necessary.
• Develop an ability to use support when experiencing emotional distress. 
• Developing a toolkit of different coping skills. 
• Receive medication management services for mood disorders and stabilize these co-occurring disorders. 
• Begin creating personal motivations for recovery. 

Residential Treatment Programs

Residential treatment facilities are facilities that provide 24 hour stabilization and surveillance.  They monitor eating disorder behaviors as well as any co-occurring diagnoses. They are not necessarily connected to hospital systems and have a more homey feel to them.

Individuals live on site.  They attend all appointments, meals, and therapeutic groups on site. Individuals may have already attended a PHP level of care, and felt unsuccessful at implementing plans/goals outside of treatment. Residential facilities provide a higher frequency of appointments with an individual’s multidisciplinary team. Generally, an individual meets at least weekly with medical doctors, therapists, dietitians, and psychiatrists. 

Labs, weights, and vitals are taken on a weekly and/or daily basis to continuously ensure medical stabilization. All meals and snacks are supervised and appropriate supervision is put in place to control for exercise compulsion, restriction, binging, and/or purging behaviors. Although, individuals may be experience urges for self harming behaviors or suicidal thoughts, these individuals are able to work with their team to decrease behaviors and contract for safety.

Generally, individuals in residential treatment should be medically stable and any medical issues controlled on site. Many individuals may feel that the eating disorder is too strong and struggle to find personal goals for eating disorder recovery.

While on site, individuals are generally working and developing the following goals, although many individuals will have unique goals to their situation: 

• Developing personal motivation for recovery.
• stabilizing and decreasing eating disorder behaviors with 24 hour surveillance
• Leaning into eating their meal plan 100%
• Taking medications as prescribed, while discovering an appropriate medication management plan.  
• Learning to feel emotions, while developing resources, coping skills, and utilizing support symptoms versus using eating disorder symptoms. 
• Ability to contract for safety.
• Weight restore when necessary.

Inpatient Treatment Facilities

Eating disorders, although a mental illness, cause serious medical complications. At times inpatient treatment or acute medical care in order to progress and even begin to lead to long term recovery. When stabilized, individuals can transition to a lower level of care. Inpatient treatment can help stabilize abnormal lab work and or vitals (heart rate, EKG) through appropriate interventions, provide fluids for dehydration, attend to acute effects of malnutrition, and help clients remain safe that are a harm to themselves or others.

Inpatient facilities can also provide tube feedings (although some residential facilities may be equipped with this service) who are unable to feed themselves. Generally the main goal of inpatient treatment is to stabilize a client physically/medically.  Once stable medically, a client can engage in more treatment at a different facility that feels like a whole person approach taking into account both physical and mental health goals. 

Recovery is Possible.

Although this is a confusing time and you still may not be sure where to begin, remember recovery from an eating disorder is possible and happens everyday. You are not alone in your struggles. If you are unsure where to start or what treatment option is right for you, please reach out to a therapist at Monarch Wellness & Psychotherapy. We would be happy to help you navigate this process and develop a treatment plan that works for you!

Resources:

1. American Psychiatric Association Work Group on Eating Disorders. Practice guideline for the treatment of patients with eating disorders, third edition.
2. National Eating Disorders Association (NEDA). Levels of care.

 

Carissa Hannum LPC is the Clinical Director of Monarch Wellness & Psychotherapy, where she provides clinical supervision and consultation on all Monarch cases.  She specializes in working with people who are dealing with eating disorders, trauma, chronic pain, and the intersection of these issues.

 Other blogs by Carissa Hannum:

• • • • • • • • • Chronic Pain & Eating Disorders
                • Looking Beyond Your Child’s Eating Disorder Behaviors