The most pressing concern is how to be sure an inpatient stay fits into the recovery plan. Eating solely to improve short-term health is of little consequence to real recovery. Although the decision to seek a residential program can be harrowing for a patient and her family, it is often followed by a sense of relief on all parts. Just the act of doing something concrete gives the illusion that full recovery is near.
Certainly for many patients, this respite can act as a springboard for more effective treatment after discharge, but a significant minority relapse and return to their pre-inpatient physical state before long. For these patients, restoration of health is not sufficient to overcome the relentless thoughts and compulsions of the eating disorder. And there are times that this sequence of events is more demoralizing than just staying the course.
For the patient with her first, second or even third episode, the professional consensus is that residential treatment is a necessary step. As I have discussed prior, resuming eating and normalizing body function can be enough to stem the onslaught of an eating disorder--especially early in the course of the illness--and to lead to full recovery. However, the patient and family need to understand the purpose and limitations of an inpatient stay, most importantly that the end result is not that the eating disorder just disappears.
Inpatient recovery exists in a bubble without any of the pressures and stresses of daily life that lead someone back to the eating disorder symptoms. On the most basic level, the patient needs to learn new ways to cope with the world and her feelings once she has returned back to her life. A clear, directed treatment plan needs to be in place long before discharge. Everyone must be aware that the inpatient program is a stepping stone towards recovery and not a magical cure.
For patients considering hospitalization after a protracted illness, the decision process looks very different. The severity of the physical symptoms takes precedence. The person's medical status needs to be the top priority because a lengthy but effective treatment does no good if the patient's health completely deteriorates during the process. Inpatient treatment becomes necessary when the person is at high risk to maintain her health and well-being, no matter the other gains in recovery.
However, people who have been struggling with an eating disorder for many years have become accustomed to feeling very ill most of the time. Because of their unusually high pain tolerance combined with the shame of being ill so long, patients find it very hard to admit to their fragile physical state. Even families begin to get used to the patient being sick. The therapist and doctor need to regularly assess the patient's medical condition and reinforce how dire her suffering is and the necessity of trying to be open about her physical state.
At the same time, after a series of hospitalizations, patients and families are aware of the limitations of an inpatient program. The history of disappointment added to growing hopelessness makes it hard to commit to such a disruptive and costly decision in recovery. Medical stability and breaking the eating disorder cycle become the only clear gains of hospitalization. But even when treatment is moving forward, a residential program can be a critical step because it may very well afford the patient more time in a stable medical state to get well. Another round of inpatient treatment often appears to the patient and family to be a futile merry-go-round rather than a part of a larger recovery, but a frank discussion about the purpose of this step often is extremely helpful. The result is to ensure that the patient's physical well-being remain a crucial part of the larger picture of recovery.
The other roadblock to making a clear and useful decision is the patient's role in the process. Someone with a chronic illness needs to reclaim some autonomy when inpatient treatment seems likely or at least a serious consideration. She can't feel like she is being shipped off to the hospital again like a child. These patients are full-fledged adults and, accordingly, can make their own decision about treatment. I have encountered too many patients well into adulthood still submitting to the will of families or paternalistic therapists who imply that having an eating disorder renders a person incompetent. There is no doubt that the eating disorder thoughts, at their most powerful, can affect someone's judgment, but almost all patients can weigh the options with a therapist and make a reasonable decision. The result is a patient who feels empowered by her own role in treatment decisions and feels much more willing to try to take an active part in making this commitment worthwhile.
The second way a patient with chronic illness takes hold of her treatment is a bit paradoxical. As I have stated before, an eating disorder effectively isolates someone from the world around them. There is no room for people and especially intimate relationships when the thoughts and behaviors of an eating disorder consume all of the time and energy a person has. One relatively new treatment program called the Maudsley method is aimed at treating adolescents with anorexia. The protocol entails the patient relinquishing all decisions about food to her parents who supervise every meal and snack and are an integral part of the treatment process at each step and each appointment.
It is a new concept to apply this approach to patients with chronic eating disorders. An adult cannot have her independence taken away, but she is also acutely aware that she cannot eat normally on her own: the eating disorder thoughts remain too powerful. The general idea is to formulate an individual plan to include an important person in her life in the daily process of eating. This is another powerful way to let someone in. I will elaborate on this idea in the next post.