Residential Treatment

The most distressed call always comes from someone who wants to discuss residential treatment. The questions abound: what's the best program? where do you send people? how do I figure out what I need? will it help me get better? do any of them take insurance? what do I do afterwards? I usually take a deep breath and try to steer the conversation away from the sense of panic. That starts with a few basics about inpatient treatment. There are good programs, but they don't cure anyone. A real treatment plan involves an informed decision about inpatient treatment, if it is necessary, followed by a reasonable, flexible and long-term plan for aftercare. Residential treatment won't speed anything up, but it can help a very sick person get well enough to function and to think, and that is a big step towards really being able to start treatment.

The first thing to know is that there are a lot of treatment programs. The second thing is that most of them are new and have almost no proven track record. After a little research, the process starts to feel like choosing between spa vacations, not eating disorder recovery. There appears to be treatment alongside the yoga and horseback riding, but each new center only helps further glamorize eating disorders as it promises a quick and longlasting recovery. In truth, there is a lot of money to be made from these programs. They start at $30,000 per month and only increase from there. Without any clearly proven treatment, each program can promote its own mix of nutrition advice, philosophy, and mindful activity with a promise of full recovery. Naturally, this kind of business plan can lure people into the residential treatment world. Yes, these programs only need to jump through the legal hoops but pass no clinical muster. I always find this a terrifying thought and shudder at what passes for treatment and recovery.

Inpatient treatment exists in a bubble. Outside the walls of the program, a patient has to learn how to handle relationships, work and family and how to avoid triggers for the eating disorder behaviors. You can teach coping strategies in a program, but you cannot truly test them. It is very hard work to live in a program and not engage in the eating disorder, but there is no choice. So residential treatment is just a stepping stone, but real recovery happens in real life. This may seem obvious, but then why don't most treatment programs recognize how critical a discharge plan truly is?

Any time a patient of mine chooses to be in a residential treatment center, I believe the most important and immediate decision is what will happen when she returns home. Too many people leave residential treatment and then slowly lose the gains from all of their hard work without ever having established a complete outpatient treatment program. Setting up that team needs to be among the first steps of an initial inpatient treatment plan. In effect, programs set patients up to fail. How can a program offer recovery and then have no plan for aftercare? Do people need multiple hospitalizations to get better or is the system organized that way? Even more concerning, is it all just about the profit?

The role of residential treatment is for short-term stabilization of symptoms. Look for programs with a long track record. Also, the philosophy of the director reflects heavily on the program, so do some research on that person. Their training, experience and availability mean a lot. Also--to hammer a point home--ask about discharge planning immediately.

I do believe residential treatment can make a difference. Some people need a safe environment with almost constant attention to get healthy enough to work in an outpatient setting. But many others would benefit from a cohesive, experienced, outpatient treatment team. What comprises an effective team? What should you look for and how will you know when you've found it? Look for the next post.


Let's Start with a Question: Taking the Plunge

Several years ago, when I was in the process of moving back to New York, a patient sat me down at the end of a session and said she knew best how to start a practice working with people with eating disorders. She suggested I create a website and let patients find me online. This is somewhat unorthodox for a psychiatrist so I thought long and hard about the ramifications of this decision. But after several lengthy discussions, I thought I understood what an online presence would mean for my practice. For many reasons, people with eating disorders feel much more comfortable finding treatment on their own, but I think it boils down to two central ones: anonymity and the difficulty in finding experienced providers. Hopefully, I could provide an online contact to help lead people to the right treatment, either with me or with another resource. I have since received emails and calls from patients, mothers, fathers, siblings and other treatment providers all looking for help in one way or another. They are almost universally surprised at how hard it is to find adequate care and appreciative of any useful leads or guidance.
Despite our country's fascination with eating disorders both in celebrities and in our own communities, there is so much confusion about eating disorder diagnosis and treatment. Anorexia and Bulimia are the only disorders recognized in the field of psychiatry: every other set of symptoms is filed away under Eating Disorder Not Otherwise Specified. In my experience, almost anyone sick more than a few years has EDNOS, which means that even the classification system is woefully inadequate. In addition, there appear to be few practitioners trained to handle the complexities and struggle involved in eating disorder treatment and recovery. Here in New York City, where it often feels like there are more therapists per capita than anywhere in the world, it can be hard to find people able and willing to help patients with eating disorders. After insurance is taken into account, the process of finding treatment exhausts even the most persistent. I have had countless conversations with patients and family members desperate to find someone willing to help them navigate the system to find the right treatment.
But those were the calls I had anticipated.
The other kind of calls caught me off guard. One morning, a few months after I put up my website, a father called in a huff of anger, apparently right after an argument with his wife at the breakfast table. He wanted me to settle the debate, and I quickly realized that my availability online might mean something very different. He was calling about how to feed their six year old daughter. "She never eats," he said. "We keep putting food in front of her, and she just doesn't like anything." Understandably, they were at their wits end. He insisted they should just let her eat when she wants to, and she said they should force her to eat her meals. She insisted their daughter needed to eat healthy food no matter what, and he wasn't so sure it was worth the prolonged battle every day. Apparently, my answer was going to resolve the debate. Did I belong here? Was this where my training led me: all the way back to the formative years of eating? I had my own internal debate at that very moment: stay focused on the treatment of people with eating disorders or consider my role more widely as a source of knowledge in the muddle of addressing food and weight in our society. I felt this was a turning point: remain the neutral psychiatrist focused on his work or take the plunge. Plunge into what? That I had not figured out yet.
"Just let her eat what she wants and give her a range of choices. She knows how to eat and will remain healthy. Nothing to worry about," I said. He was palpably relieved.
I, on the other hand, remain hesitant and confused, but I have not looked back. Even more deeply rooted in our society than the fascination with eating disorders is a disorientation and confusion about food: what to eat? what not to eat? when to eat it? what is healthy food? what should I feed my children? The questions are endless, and people apparently have no reputable source to go to for answers other than doctors. Since I talk to people about food all day and think about what is normal and abnormal eating, perhaps I was a reputable source.
I thought I could start to answer some of the more universal and pressing questions I receive by writing about them. Some of the topics may relate primarily to eating disorder treatment, but many questions relate to the reality of struggling with food and weight in our society. I know I often have sound advice and useful guidance about treatment for an eating disorder. However, I also believe that talking and thinking about food and weight has put me in a position to offer insight and guidance as to how to handle these issues for the curious, not just the sick.
With all of this in mind, I have decided to take the plunge.