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.

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