The Current Role of Residential Treatment for People with Eating Disorders

I have written at length recently about some of the troubling changes in the residential eating disorder treatment programs. Granted, my concerns about residential treatment have shifted during my years of practice at first from lack of access to residential care and now to the quality of care.

Because these illnesses are less of a focus to psychiatry programs across the country, eating disorders don’t have a clear, effective standard treatment plan. Thus, these programs are on their own to develop a strategy that seems appropriate. Clearly, this open debate allows programs much too wide a berth in their decision making.

Despite the varied, serious concerns, there still is a place for residential treatment for people with eating disorders. Some programs do a good enough job and many an adequate one, at least for certain patients.

The most common situation that merits residential care is a patient’s first serious episode of an eating disorder with medical consequences. If a patient is newly diagnosed, unable to curtail symptoms with sufficient outpatient care and at medical risk, then residential care is a reasonable and often necessary option. Treatment can stabilize health, provide education about the illness and inform the patient about the process of recovery. The risks are exposure to people with much more severe symptoms and the introduction of concept of the eating disorder as one’s identity.

Care needs to be taken for first time patients that they don’t end up in a revolving door of treatment. The deleterious psychological effects of ongoing residential and hospital care can cause long-lasting damage that may even outweigh the toll of the eating disorder itself.

Repeat admissions to residential care need to be considered cautiously. The risks of a first admission escalate significantly with subsequent admissions. Anyone returning to a facility needs a clear plan and hopefully a shorter time in treatment followed by a return to their lives as quickly as possible. Cycling through various programs makes people feel hopeless about their lives, unable to envision a future and identify increasingly with their illness. Outpatient clinicians must consider these various effects as much as managing the eating disorder itself.

For people with a longstanding eating disorder, programs are best used as a last ditch option. If someone is stuck in a behavior pattern with serious medical consequences, then a short term stay no longer than a month is best to stabilize the condition. There is nothing new to learn about treatment at this point, and it’s best to return to their regular lives as quickly as possible.

This post is meant to counter some of the concerns about residential treatment I have enumerated in recent months. There is a place for residential care in eating disorder treatment when considers thoughtfully and used judiciously.

The Unexpected Opportunity of Government-Approved Low Cost GLP-1’s

Last week the announcement that GLP-1’s would have price caps in 2026 was no surprise. Anyone following the GLP-1 industry knows that these meds are a phenomenon, a capitalist, not medical, breakthrough. With lowered prices and pill versions fast tracked, Ozempic et al. changed the landscape of the profitability of health care and the entire medical/diet/exercise complexes.

Rest assured, these changes are not related to the overall health of Americans. All signs point to a market too large for the current system to handle. Compounding pharmacies and online GLP-1 bodegas swept up the leftover profit with only a faint whisper of medical attention. The online companies have more in common with a smoke shop than a medical office.

No one knew what these meds were going to do to our society. Anyone and everyone feels drawn to the miracle shot and the fantasy, not reality, of a perfect body. From people who were minimally affected by media and thinness to those with lifelong eating disorders, people can’t escape the lure of the magic injectables.

Not only are the medications here to stay, but they also have changed medicine for good. After years of blaming patients for their various maladies due to being overweight, doctors now have a supposed cure at their disposal which is reinforced to patients every minute on social media, pressed upon clinicians by big pharma and suddenly available to most people by the government.

The next step is clear for medicine, even if the goal is a stretch for the zombie-like approach to medical care these days. Rather than follow the pharma company’s and health insurance juggernaut’s recommendations, doctors need to figure out how to use these medications wisely and simultaneously phase out the reliance on blame and shame about weight as an excuse not to practice medicine.

These medications help a large number of people by treating diabetes, regulating the gastrointestinal system, managing metabolism, decreasing inflammation and aiding in sobriety. Many people benefit from much lower doses than recommended, and the benefits of the GLP-1’s can buoy people to look to other ways to improve health. No doctor should treat the medications as a magic fix and absolve them of the responsibility for improved health.

These medications are likely to be the truest test to see if medicine can function with some autonomy from the capitalist system. Health care is a the fastest growing part of the economy. Financial firms are aware of the amount of money available in this industry, as evidenced by the investment in eating disorder treatment, for example. Doctors often work for large conglomerates now and find themselves drowning in bureaucracy and overwhelmed by messages from industries with ulterior motives.

Can GLP-1’s be an entree into practicing better medicine? Can doctors use this intervention to help patients see the benefit of preventative medicine? Can the lure of weight loss, the unabashed panacea of the medical establishment, help doctors speak more openly to patents about their actual health, not just weight?

Perhaps it’s an overreach to imagine such a sea change in health care, but access to these injectables will bring patients into the office and give doctors a captive audience to listen to broader ideas about health. Even more importantly, patents can start to trust doctors and the health care system again.

There is no point questioning the utility of these meds. They are here to stay. Instead, we need to accept the change and consider how medicine can improve from here.

Why is Eating Disorder Treatment an Existential Experience?

After the stabilization of food, attention to meal planning and work on identifying hunger and fullness cues, eating disorder treatment is an existential process at its core.

Eating behaviors are largely unconscious and automatic. Similar to other animals, the human drive to eat and survive is necessary for our species. The conscious ability we have to decide what to eat, when to eat and how to eat pales in comparison to our fundamental need to eat to live. When given the choice between any philosophy about eating and food as survival, the human instinct to persist always wins.

Regulating eating patterns enables us to feed our bodies appropriately. Within reasonable guidelines, our bodies don’t care too much how we eat but don’t like to be subjected to insufficient eating over long periods of time.

What makes eating disorders so intractable is really not about the food. Instead people with eating disorders develop all psychological, behavioral and emotional aspects of their lives around the rules of disordered eating. Disentangling this web feels like tearing apart the soul, an unenviable task for anyone.

Eating symptoms start at a young age and fill the need to learn coping skills in the formative stages of life. At a time when identity is vague, emotions are strong and the need for an anchor overpowering, food and body can become an incredibly stabilizing force.

People often turn to food to manage all kinds of emotions from frustration to sadness to joy. For many, food is an automatic way to experience and tolerate emotion and experience. Eating behaviors obviate the need to look for other ways to cope.

Body shape and eating behaviors are powerful means to create identity. Our world values public food restriction and thinner bodies as true achievements and as signs of moral superiority. In this regard, some eating disorders provide an immediate identity that is very grounding.

In a much more painful context, people who spend years of their young life in treatment can develop an identity as a scapegoat and identified patient in the family. The personal recognition of attention by being sick can create identity that is painful and limiting, but equally powerful.

These are a few examples of how an eating disorder can affect psychological development. The effects on body and eating patterns are profound and the creation of a framework to understand and oneself very straightforward.

Then, after the focus on food, therapy needs to recognize how strong the psychological hold of an eating disorder is and create a path to learn an entirely new way of being. In therapy one can work on finding new coping mechanisms for daily living, experience emotions in different ways and explore a deeper sense of identity outside of food and body.

These are not simple tasks. Learning so many ways to function in the world demands a willingness to remake and rework our fundamental sense of ourselves and to open up difficult and often frightening vulnerabilities.

No other mental illness necessitates therapy on such a profound level to get well. Recovery is so hard because one needs to truly break down the self built on eating disorder beliefs and find new ways to exist in the world. The result of this work is very powerful and meaningful. The path is hard.

Patients who get Stuck in Residential Treatment

In recent years, I have seen more people go to treatment around ages 16-19 years old who proceed to get trapped in several years of an endless cycle of residential and outpatient programs. Although some patients did go through similar experiences in the past, the number of people languishing in this cycle seems to be increasing.

Typically, these are young women with anorexia who have little incentive to change their eating, for either psychological or physical reasons, and who are very vulnerable to the messaging in eating disorder programs. These messages instill blame and shame around not being able to “fully recover,” thus reinforcing the negative self-image at the heart of an eating disorder.

The combination of a sense of failure to follow the guidelines of programs and the shaming about having an eating disorder leave this cohort of people hopeless and alone. Even involved families are convinced that there is no other option for recovery.

These patients are forced to integrate the hopeless and helpless state as part of their eating disorder identity and then feel the pull give up on themselves and their future. The resulting trauma from treatment often overrides even the struggle with the eating disorder itself. To a person, this cohort reports that their self-worth tumbled dramatically after entering treatment.

Some find ways to exit the cycle often through extreme measures such as a feeding tube for regular nighttime formula feeding or avoiding any health care providers who might force them into treatment again. The result is more isolation and increased fear of seeking any help that may lead to being imprisoned in treatment again.

It’s hard for me to ignore the fact that private equity investment in eating disorder treatment seems to encourage a revolving door of patients who provide an unlimited pool of insurance money for these programs. For the group of people in and out of treatment for years, it’s clear that the current state of eating disorder treatment is not working. No one should have to repeat treatment that’s punishing, cruel and ineffective.

That’s one reason I’m looking into other possible medical causes for some eating disorders. Many of those mentioned above have MCAS symptoms, which I have written about in recent posts. Providers ought to include MCAS screening for newly diagnosed people with eating disorders, especially Anorexia, to assess if the difficulty eating is connected to MCAS. Forcing people to eat may very well be torturing them by worsening these uncomfortable, painful and sometimes debilitating mast cell symptoms.

Eating disorder treatment providers need to stop relying on methods that often fail and can be traumatic and instead think outside the box for new ideas. Even referring to higher level of care, which may be clinically appropriate, often causes irreparable psychological harm to people just learning about their eating disorder and starting to get help. Our goal must be to help and heal, first and foremost.