Thoughts about the Transition from Residential to Outpatient Treatment

One of the rockiest parts of eating disorder recovery is the transition from residential treatment back into real life. Navigating that step plays a large role in the benefit the inpatient experience can give. 

Although treatment programs provide many necessary and valuable opportunities to help people challenge the eating disorder thoughts, certain parts of the illness lay dormant.

Ultimately, all food decisions are made by the program, so the internal struggle between restricting food and eating a sufficient meal is moot. Regular nourishment and improved health both substantially decrease the eating disorder thoughts, but the insidious urges to follow a trail back into illness remain. 

Treatment programs attempt to inculcate patients to sign on fully to recovery, to believe in their desire to be well, as a hedge against the inevitable return of these thoughts after discharge. This dynamic sets up a confusing and somewhat unrealistic situation upon re-entry into the world. 

The crux of a sufficient discharge plan lies not with the perfect arrangement of treatment providers. A well designed plan with gradual step down from more to less intensive outpatient programs combined with an experienced, caring and communicative team does not guarantee full recovery. The likely success of the transition rests instead with a plan to face the ambivalence, confusion and daily struggle to contain the eating disorder thoughts, a very individual and personal effort. 

Two aspects of treatment at this stage are critical. 

The first is the openness and honesty of the patient in treatment. The track record of anyone who entered residential treatment shows that battling the thoughts alone will lead to a likely relapse. Any way to be open about that daily struggle with any part of the treatment team means the person is not facing recovery alone. In and of itself, this openness changes the dynamic of daily life. 

The second is transforming ambivalence of recovery from another shameful or guilt-inducing part of this illness--a mental state likely to encourage relapse--into a natural part of the process. The idea of leaving behind something that has been a central coping mechanism and a source of individuality, despite the obvious negative effects as well, is very difficult. It's natural to experience mixed feelings when going through a deep, emotional and personal change. 

The transition from residential to outpatient treatment remains complex and challenging. Openness and acceptance of the ambivalence will help make this step even more successful for patients.

Ownership of Eating Disorder Recovery

Treatment for people with eating disorders has adopted much of the language used for addiction, most specifically the confounding term motivation. 

Motivational interviewing is a theory of addiction treatment that delineates the stages of the process of recovery. The addict moves from being fully into the addiction to recovery through a series of steps with increasing motivation, an unfortunate choice of words to describe healing from an illness.

The theory accurately recounts these stages and gives structure for a therapist to follow but does not have a clear methodology to create motivation because that is not what enables someone to get well. In the end, this term places blame on the patient for having an illness and not knowing how to get better. 

Likewise, therapists can posit that patients do not have the motivation to get well from an eating disorder and absolve themselves of any responsibility for the outcome. This scenario often leads to a stalemate: go to a "higher level of care" or else treatment won't work. 

I do not mean to imply that more intensive treatment is ineffective. Much to the contrary, it can make a significant difference. Instead, I want to point out that finding motivation is not the barometer of success or failure for the patient. This paradigm is not conducive to recovery because placing blame on the patient reinforces the idea that recovery is impossible and the need for the eating disorder overwhelming. 

If the eating disorder is seen more as a way to approach the world rather than an illness, the process of recovery, and the empathy of the therapist, looks very different. Taking away one's central coping mechanism will lead to a dizzying, disorienting transformation. Only a true sense of unhappiness and despair living in the illness is likely to lead someone with a chronic eating disorder to want to make that change. 

However, once the patient sees a path towards wellness, she will have true ownership of her recovery. It is ownership, not motivation, that is the goal of treatment. Ownership implies that the patient has the autonomy to live her life, with or without the eating disorder, no matter how hard that might be.

The purpose of a therapist changes drastically when the goal is to help find ownership rather than motivation. The responsibility lies within the therapy to consider recovery as a viable option, a path not to be forced but to be found. Most importantly the discussions can encompass compassion and collaboration, not ultimatums and blame.

The Cons of Looser Boundaries in Eating Disorder Therapy

People with eating disorders have often intertwined their identity and sense of who they are with their illness. Even calling it an illness can be frustrating to hear. It doesn't feel like naming a disease but instead seems like a personal attack on one's character.

For people with this conception of their eating disorder, there is no clear distinction between the illness and themselves. Any interaction is, by definition, an interaction with the eating disorder. 

This fact makes looser boundaries in therapy tricky. Openness in treatment is effective in large part by communicating that the personal connection is between the therapist and the patient, not her eating disorder. This concept can feel not only abstract but almost impossible to those who view the eating disorder as an integral part of themselves. 

In this scenario, the closeness and connection in the therapy relationship, which is very real, either leads both parties to ignore the presence of the eating disorder altogether, thereby colluding with the illness, or to work around it with little success, ignoring the elephant in the room. 

If the looser boundaries enable the person to see how limiting the eating disorder can be and how much it interferes with living life fully, then the therapy can start to create enough distance from the illness to separate it from identity.

If the person cannot pull away from the eating disorder, the relationship begins to feel hollow. A connection built on the foundation of an eating disorder will not have enough solid ground to continue unless the goals shift away from recovery. 

It is a painful realization to know that therapy has made a difference in someone's life yet has been unable to separate that person from her illness. Because of the looser boundaries and the intensity of the connection, the emotional fallout from this realization can be strong. In what seems like a last gasp, the power of the moment can sometimes galvanize the treatment to have a more profound impact. It is critical never to lose hope, neither therapist nor patient. 

The end result is that the therapy relationship has to be a true bond to have success in treating an eating disorder. The subtle ways an eating disorder clings to a person, an insidious virus boring into her life, are so hard to overcome. The boundaries, openness and trust are all crucial pieces of recovery. There are risks in that type of treatment, but the potential benefits far exceed the downside. 

Looser Boundaries in Eating Disorder Therapy

The benefit of reconsidering the boundaries in therapy for someone with an eating disorder is straightforward. The feedback from patients and evidence of its success are both very strong. 

The boundaries in therapy were originally aimed at creating an environment in which the patient can objectively analyze and understand emotions and behavior. The relatively blank slate of the therapist acts like a mirror for the patient to better understand herself. The therapist works hard to reflect observations of the patient to help her make better sense of her inner self and interpersonal relationships. 

Eating disorders are almost like insidious viruses in the mind. The illness starts at a formative age when identity is still malleable and confounding. The physical manifestations of the eating disorder generate a lot of response, often positive. This feedback loop tends to reinforce the thought process of the illness and cements it as a core part of identity. 

By the time the person realizes the destructive presence of the illness, the thoughts are such a central part of the self that separating the two feels like an exercise in futility. 

If the therapist erects firm boundaries and invites the patient to look inward, therapy just reflects back the obvious: the patient has an eating disorder that is a strong part of identity. 

Effective therapy for eating disorders needs to break down typical boundaries and create a much more genuine relationship between therapist and patient. The goal is for that connection to be established between the therapist and the healthy part of the patient, the non-eating disorder part.

This bond, a critical one to learn for recovery, allows the patient to see that powerful relationships outside the purview of the eating disorder, increase the impetus, over time, to challenge the thoughts and do the work to stick with recovery. 

Patients often say that the effect of this therapy is that they feel seen or heard without the eating disorder symptoms. That feeling of recognition can serve as a strong motivation to believe true recovery is possible, a necessary component of any effective treatment. 

The most significant downside of these boundaries is for the patient either slipping or in a relapse. That person has lost all connection with the healthy part of herself, the part not connected to the eating disorder. It makes it feel like any genuine connection in therapy is lost, and that loss causes enormous pain. Returning to recovery will quickly bring back the real relationship in therapy but can still take work to mend.