Dropping Patients Who Aren’t Improving is Very Risky

Many clinicians in the eating disorder field feel comfortable discharging patients who aren’t getting better. If a patient isn’t making changes with food, is at a low weight and/or has abnormal lab values and isn’t making steady progress, doctors, therapists and nutritionists alike feel justified in saying they can’t help anymore. The only option is a higher level of care.

I have written about this standard protocol of treatment many times in this blog because I continue to be shocked that providers who are supposed to help struggling patients can so easily drop them.

The explanation for these decisions is twofold. First, if a patient needs more care, allowing them to continue substandard care will lead to a dangerous outcome. Second, and more to the point, clinicians don’t want the liability of treating a patient who might get very sick on their watch.

In the end, the decision to drop a patient always benefits the provider, never the patient.

A treatment team is obligated to try to help a patient in the process of recovery. Therapy can shift to focus on all the reasons a patient is scared to get more help or to make progress with food. The team can consider support in other ways that represent a compromise between higher level of care and continuation of the current plan. Medical interventions can attempt to manage the effects of the eating disorder with electrolyte or vitamin supplementation.

Dropping a patient is not the only option.

The very harsh decision to end treatment with a patient makes them feel like the eating disorder is their fault and that recovery is just a matter of willpower, very much not the reality. The clinical misjudgment reinforces the patient’s belief that they are the bad one and that the idea that they are damaged must be true. Why else would the team drop them?

In fact, a standard type of therapy used for eating disorder and substance abuse treatment is called motivational change. The first step in getting help is called the precontemplation phase. In this step, the patient is considering real change and needs the space to be able to sort through their own internal obstacles in order to move forward.

Why can’t eating disorder clinicians provide these steps? Why can’t the same clinicians discuss the medical risks at length and still continue to provide support? Why drop someone trying to figure out how to get better?

Recovery from an eating disorder is hard work. The physical steps of eating more food, tolerating fullness and digestion and seeing one’s body change are very hard. The psychological steps of feeling emotions more intensely, exposure to others without the numbing of the eating disorder and losing the ways an eating disorder feels like a protector are hard as well.

A knowledgeable clinician understands these struggles and can provide meaningful care and attention to help them move forward in recovery. Isn’t it an obligation for all of us to provide this care?