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Intensive Outpatient Treatment Program Offers Flexibility, Individual Attention

Reprinted from Eating Disorders Review
September/October 1999 Volume 10, Number 5
©1999 Gürze Books

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 (formerly the Toledo Center for Eating Disorders, Toledo, OH). Dr. Garner, Julie Desai, and other staff members described their intensive outpatient program during a workshop at the recent Academy for Eating Disorders annual meeting in San Diego.

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." Another advantage is that a therapist working in an intensive outpatient treatment program has the leverage to help patients move back and forth between programs, as needed, creating a very beneficial continuity of care.

The Setting
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, at least 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 30% of patients come from outside the immediate area and two-thirds are 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.

To avoid the types of problems that managed-care systems have with flexible treatment times, the center makes certain in the beginning 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 who live in the area 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 and social contacts. 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.

Continual Monitoring
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. "We ask patients to take a moratorium from anorexic thinking and from their anorexic eating style, to give them some experience in eating in a way clearly not related to anorexia nervosa," he said.

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.

Weight Goals
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 with a patient, 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.

Working with Other Professionals in the Community
The staff also works closely with primary care physicians, psychiatrists, and other professionals in the community, to help the patient prepare to go back into the community once treatment is over. A good part of the staff's work in intervention involves collaborating with schools and guidance counselors to make sure the client gets homework assignments and to let teachers know what is going on.

An internist, psychiatrist, and nutritionist act as staff consultants. The internist is available whenever patients have medical difficulties or serious problems with any complication of treatment. The nutritionist helps with meal planning. There is a strong emphasis on follow-up and prevention of relapse.

Family Therapy
Dr. Garner noted that family therapy takes many forms at the center-there is more than one model. 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. As Dr. Garner explains, "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, such as relationship problems or eating management issues."

Staff Meetings
Frequent staff conferences, sometimes 3 to 4 a day, help prevent and minimize frustrations, splitting, burnout, and excessive negative countertransference. These meetings also help intercept little problems before they escalate. They might take the form of therapeutic meetings in which staff members touch base with one another to follow up on a patient who has been having difficulties around certain food-related issues or interpersonal problems. "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."

Follow-up
The staff also keeps close telephone contact with parents. If parents if they 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.

A recent case underscored the versatility of services that an outpatient intensive care program can offer. In a reverse twist on the ordinary concept of level of care, a patient was losing weight and not eating in a local hospital, so her parents took her out of the hospital and enrolled her in the intensive outpatient program. The hospital staff had been confused about how to handle the patient's refusal to eat. She did well at River Centre, according to Dr. Garner because, "The staff has a great deal of experience in providing specialized treatment with this population, and it is our impression that staff experience, as well as operating within a good theoretical model of care, are the cornerstones of effective treatment."

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