Discharge Planning

Treatment programs have a valuable but very specific role in recovery from an eating disorder. The focused and intense time spent on getting better empowers people to realize that full recovery is a viable endpoint. People learn an enormous amount about their illness. The immediate gains are obvious and, in a positive environment, even points of pride.

In addition, spending time with a group of people all zeroing in on treatment is a relief after months or years of isolation from being sick. Above all, a sustained period of being nourished diminishes the physical, emotional and psychological symptoms of an eating disorder drastically. More often than not, people complete a program in a better place than when they started. Although that may seem like an obvious statement, intuition is often not helpful when it comes to choosing treatment for people with eating disorders so this is a crucial fact to remember.

Still, entering a program isn't the best choice for everyone despite the likely short-term improvement. Research and experience prove that these gains don't last more than a few months for most people for several reasons.

Eating disorder treatment is time-consuming and expensive. Much thought needs to go into the decision both in terms of potential benefit and the likelihood of treatment kick-starting true, long lasting recovery. No one has enough resources to make repeated hospitalization a viable option: it only reinforces that an eating disorder is a chronic, incurable illness.

A quick relapse can be incredibly demoralizing and delay recovery for months and years. Too many people who go to treatment programs prematurely just cycle through the different options for treatment without any true progress. Granted, medical emergencies such as being severely malnourished or low potassium from purging may necessitate urgent inpatient treatment; however, it behooves clinicians and patients to consider likely outcomes before committing blindly to a detrimental course of treatment.

Any reasoned approach to residential treatment must include discharge planning at the very start of the treatment. Too many programs are so intently focused on the day-to-day operation of their bubble that they neglect to fully consider how challenging the transition is from 24 hour support to just a few hours per day at most. Even the best programs struggle to include the outpatient team in treatment decisions and discharge planning, even though it's the outpatient team that will implement the treatment and that knows how reasonable and realistic the plan is. Outpatient clinicians feel they can take a break when a patient goes into residential treatment, but that only worsens long-term outcome.

Discharge planning needs to start on the day of admission to residential treatment. Doing so will force inpatient and outpatient teams to communicate right away. That interaction will uncover basic assumptions of both teams and allow for debate and thorough consideration of all possibilities.

Moreover, it will give time to present the options to the patient so she can have a say in the process as well. A patient involved in these decisions will have ownership of the treatment and will be much more like to follow through. 

Since the benefit of these steps is pretty obvious, the real question is why doesn't this happen automatically? I don't have a good answer. Part of it may be the disjointed nature of care for people with eating disorders. There are no guidelines for transitions in and out of residential programs. Also there tends to be a sense of superiority in American clinical care which enables competition between various stages of eating disorder treatment, not collaboration. Finally, the lack of any centralized health care agency means there is no accountability for clinicians in their decision making, a necessity to keep clinicians honest and humble.

The bottom line is that discharge planning and continuity of care needs to be of primary importance. It's the key component for treatment programs to be steps in recovery, rather than brief blips of wellness.

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