Bridging a gap in eating disorders services
September 10, 2013 by Dawn Delgado, MS, LMFT
Roughly 10% of men and 30% of women entering treatment for drug or alcohol addiction also suffer from anorexia nervosa, bulimia nervosa, or binge eating disorder. In order to treat the whole person and improve long-term outcomes, addiction professionals must not only recognize the signs of these eating disorders, but also have a firm understanding of eating disorder treatment options and trends.
In this article we explore a new innovation in eating disorder treatment: the 11-hour extended day treatment (EDT) program. Through the lens of “Lisa,” a psychologically vulnerable, opiate-addicted client whose weight is in the double digits, we will see how the EDT program can help bridge a critical gap between inpatient treatment and a partial day program.
Imagine Lisa is your client. As you look at her, you realize that her protruding ribs and emaciated structure are visible indicators of life-threatening malnourishment. You know that both the physiological destruction caused by her addiction and her starvation mirror the neurological and psychological trauma that underlies her multiple diagnoses: anorexia nervosa, post-traumatic stress disorder (PTSD), debilitating anxiety, opiate addiction and clinical depression.
Immediate action is taken to help Lisa get the medical care she needs. She is sent to an inpatient facility such as Rosewood Centers for Eating Disorders where she can medically detox, address her anorexic condition and receive treatment for her underlying disorders.
Lisa becomes medically stabilized, and her treatment team keeps you informed of her progress. Within 30 days her weight normalizes into the triple digits, she begins to feel more energized, she no longer experiences fainting spells or seizures, and her lab reports indicate that her health is improving. Within this time, Lisa’s multidisciplinary treatment team helps her to begin identifying and addressing underlying trauma through psychodrama, one-on-one counseling, group therapy, and equine therapy and other experiential modalities.
Now imagine that after a decade of illness and only 30 days of inpatient treatment, Lisa (who was literally dying of starvation prior to treatment) is suddenly removed from the safety and familiarity of around-the-clock care. She travels by airplane to another city to enter a new program with a new treatment team. She is in a new transitional housing environment with new peers, and now instead of 24-hour supervision she is reduced to 6.5 hours of structured programming, six days a week. She must adjust to 40 hours of weekly care, vs. the 168 hours of weekly care she had received as an inpatient client.
So, what happens? Lisa leaves the hospital and soon begins losing weight, withdrawing from others, using unhealthy substances in order to numb, and slipping back into destructive eating disorder behavior patterns. In short, Lisa relapses.
What is the solution? What happens when she is finally discharged? How does she make the leap from inpatient care to being unsupervised 50% of the time in a partial day program?
What seems clear is that there is a need for a solution that would allow Lisa the freedom to explore independent life in recovery while still being supported by structured treatment during the vast majority of her waking hours.
This was the need that eating disorder experts Michelle Klinedinst and Robyn Caruso responded to when they created the 11-hour EDT program at A New Journey (ANJ) in Santa Monica, Calif. Facility executive director Caruso explains, “Transition from the 24-hour structure of inpatient treatment to a partial program where the client spends 65% of their waking hours and 85% of their meals unsupervised can be overwhelming for some people. ANJ’s 11-hour Extended Day Treatment program, coupled with our supervised transitional living environment, is a perfect solution for these clients.”
Caruso says that in the EDT program, clients are in structured programming for 75% of their waking hours, and the rest of the time they are often within the safety of ANJ’s transitional housing environment. This more gradual transition to independent living incorporates more one-on-one care, smaller groups, and more structured meal times.
In ANJ’s program, clients take responsibility for 20% of their weekly meals, including nightly snacks as well as all meals on Sunday. Working with a dietitian, clients plan these independent snacks/meals ahead of time and make commitments to peers regarding their eating behaviors. Held accountable for their commitments, clients discuss the outcomes of their independent snacks/meals in daily therapy sessions.
This structure allows clients to get into a rhythm and slowly internalize healthy eating patterns in an environment where relapse intervention occurs immediately. This early intervention helps clients better prepare for the next step in their recovery journey.
When ANJ clients are ready to step down from the 11-hour EDT to a 6.5-hour partial day program, they stay at the same treatment facility and often remain living in ANJ’s transitional housing units. This allows clients to benefit from maintaining continuity with the peers, location and treatment team they grew to trust in the EDT program.
“Change is difficult, particularly for clients struggling with eating disorders,” Caruso says. “The EDT to [partial day program] solution at ANJ allows clients to focus on recovery, instead of having to adapt to unnecessary changes in their treatment environment.”
Another aspect of the EDT program at ANJ is the low client-to-staff ratio, which runs at about half of the ratio in ANJ’s other programs. A smaller group with more staff means that high-risk clients are able to get the individualized care they need.
Asked about how this program is received in the treatment and recovery community, Caruso says, “Sober livings like it because their clients can get an extended day of structure in conjunction with the support they get in the sober living environment.” She adds, “Counselors appreciate the program because we are open to collaborating with outside therapists to help clients have the individualized treatment team and continuity that they need.”
This new approach to treatment is still not fully understood by insurance professionals. Caruso and her team have been working diligently to advocate for clients by helping these professionals understand that the EDT program truly constitutes a separate level of care.
“They are coming around slowly and beginning to see the potential cost savings in treatment and relapse prevention that a program like this offers,” Caruso says of insurers.
The EDT program has been so well-received by the treatment community that Klinedinst, who is responsible for building eating disorder treatment centers throughout Florida, California and Arizona, plans to introduce the 11-hour program to her newest center, Eating Disorder Recovery at PBI.
“Our goal is to improve client access to treatment, promote long-term recovery, and ensure relapse prevention,” Klinedinst says. “We feel that the 11-hour EDT program helps us reach this goal by effectively bridging the gap between [inpatient treatment] and [a partial day program].”
In the case of Lisa, who is representative of many clients who have gone through ANJ’s EDT program, the 11-hour bridge was just what she needed. After multiple times in treatment, Lisa finally was able to avoid another relapse and step down successfully to a PDP program, this time ready for her newfound independence and confident in her ability to achieve long-term recovery.
Dawn Delgado, MS, LMFT, is a consultant with expertise in eating disorder program development. She has worked with adolescents and adults recovering from eating disorders and comorbid conditions in Southern California since 2002, in inpatient, residential, partial hospitalization and intensive outpatient levels of care. She has served as Membership Chair of the International Association of Eating Disorders Professionals’ Southern California chapter. Her e-mail address is firstname.lastname@example.org. A New Journey’s Robyn Caruso can be reached at email@example.com.