Considering eating disorder treatment and not sure where to turn? Confused as to what type of treatment you need? Not sure what Residential/PHP/IOP/Outpatient levels of treatment all mean? Well, I HAVE THE ANSWERS FOR YOU! :) I’ve asked two San Diego eating disorder therapists to detail all the options of eating disorder treatment, explain how you progress through each level, and discuss how treatment can help you recover. Eating disorder therapist Edie Stark, LCSW, and eating disorder psychologist Dr. Jennie Wang-Hall are outpatient providers in private practice in Bankers Hill and Oceanside, respectively. Both of these amazing women have worked in multiple levels of eating disorder treatment, and so they have provided excellent explanations so you can make an informed decision. I’m so excited for you to read what these amazing women have to offer!
There are several levels of eating disorder treatment in San Diego: Residential, Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), and outpatient (OP) treatment. Would you briefly describe the differences among the levels of treatment?
Edie: When I first started out in the clinical side of eating disorder treatment, I was an admissions counselor at a PHP level of care in NYC. This job was instrumental to my career, as it really helped me to understand the levels of care for those struggling with eating disorders. Since then, I have worked at all the levels of care. I even interned at the inpatient level of care, prior to starting graduate school.
Now as an OP therapist, I use the skills I learned as an admission counselor to help make sure my clients are getting the appropriate level of care.
Residential is a 24/7 supported living environment. Clients live at the center, and they attend therapy groups, have supported meals, go to individual counseling. I view this level of care as a stabilizer, to help with refeeding, breaking eating disorder behavior cycles and to address an co-morbid diagnosis.
PHP is a step-down from residential, where clients are safe enough to return home at the end of the day. Clients still receive all of the supports they did in residential, and usually can begin to do some deeper therapy work, food exposures and start to learn alternative coping skills
IOP is the next step after PHP. At this point, clients may be starting to reengage with life outside of treatment, learning to balance ongoing recovery work with school, work, volunteer activities, family life, etc.
Then comes OP- For my clients to meet criteria for OP level of care, they need to be able to engage in adaptive coping skills, have emotional tolerance, and be seeing an eating disorder RD (registered dietitian). Some of my clients are still using eating disorder (ED) behaviors, and that’s okay as long as there is motivation, and the healthy coping skills outweigh the use of ED behaviors. Every case is different, and I take my clients safety very seriously. It is not uncommon that I will refer my clients out for more support.
Jennie: I have had the privilege of working in all levels of eating disorder care and have observed several important distinctions between settings. Residential is a high level of care that involves living at a home-like center where you receive full containment of eating disorder symptoms through therapeutic meals, observation, and full therapy programming throughout the day. In residential, a patient will see a psychiatrist, dietitian, therapist, and having nursing support.
PHP is still an intense level of care but often occurs at 10-hour or 6-hour intervals. As with residential, PHP offers meal supervision and therapy programming. However, PHP does not include the same level of monitoring that is provided in residential. Also, PHP does continue to involve the full team of treatment professionals.
IOP is considered to be a lower level of care, but it still provides considerably more structure than outpatient. IOP typically occurs for 3-4 hours per day, several days per week. IOP may continue to involve therapeutic meals, but the majority of the individual’s meal plan is done independently.
OP most often occurs once per week for 1 hour. OP therapy looks like a collaborative relationship where typically the patient takes the lead in pursuing their recovery with the support and guidance of a therapist.
How would someone suffering from an eating disorder in San Diego decide on a level of treatment?
Edie: Ask a professional! I often speak with potential clients during my screening call who need more support then I can give. I will give them my recommendations and a list of referrals. Your PCP (primary care physician) may also be able to help figure out what type of support you need. There are also great resources from NEDA (National Eating Disorder Association) to help guide you!
Jennie: If someone is suffering from an eating disorder and is trying to determine appropriate level of care, a good place to start is to reach out to an outpatient therapist who specialized in eating disorders. That therapist will have the expertise to be able to assess the severity of your symptoms and subsequently the amount of support and structure that will be most helpful for you. If your therapist recommends that you need a higher level of care, it can be helpful to research different treatment centers to learn about the kind of therapy that they use and whether it would be a good fit for you.
As outpatient eating disorder therapists in the San Diego area, how would you guide individuals in determining which level of treatment they need?
Edie: I assess for a variety of factors, how often are behaviors being used, are they medically stable, where they are at in terms of motivation, readiness for change, who they have for support, how many times they may have been in treatment and what levels of care they have experienced, and co-occurring diagnoses.
Jennie: As an eating disorder psychologist, I often see patients who need help in determining what kind of treatment is most appropriate. One consideration is the types of goals that a patient is working toward. If a patient is in the very early stages of recovery and is struggling with goals that are as fundamental and crucial as complying with a meal plan and abstaining from ED behaviors, a higher level of care may be needed to provide increased structure and accountability.
I would guide an individual with extremely severe eating disorder behaviors who is struggling to pursue recovery independently to consider either residential or PHP treatment. OP is my recommendation when an individual feels more confident in their ability to navigate recovery with only weekly support. OP is most appropriate when eating disorder behaviors are mostly managed and more of the discussions surround underlying contributing and maintaining factors.
Do people ever start in one level of eating disorder treatment and switch to another level? If so, when/how does that happen?
Edie: ALL THE TIME!!! It so normal to jump around levels of care, sometimes in the order that makes sense for you. A client might try out a certain level of care and realize it may be creating more issues. For example, if a client is in a less-supportive level of care and starts to regress due to doing trauma work, life stressors or moving too quickly to eradicate behaviors. Clients need to be stable both physically and mentally to begin to do trauma work safely; sometimes we don’t know how destabilizing it may be to start to unpack past or current trauma. Furthermore, recovery is not liner. It is part of process to make sure you are getting the most support you need, even if that mean stepping up to a higher level of care.
Jennie: It is very common for patients to start in one level of care and switch to another. Very often, patients begin to pursue treatment with an outpatient therapist and then the therapist will collaborate with the patient in determining if outpatient is the right level of care. If it is not, the patient may transfer to residential, PHP, or IOP. Often if a patient does go to a higher level of care, they will then step down through the less intense settings of care until they reach outpatient. So, a common treatment trajectory is OP, then Residential, then PHP, then IOP, then back to OP. The transitions from one level of care to another are determined by a patient’s readiness for additional responsibilities in recovery and ability to regulate emotions independently.
What are the most appropriate types of clients for outpatient (OP) eating disorder treatment?
Edie: I talked about this in what I look for when assessing clients for my practice. Bottom line is safety. Can they maintain their safety with the limited support that OP can offer? I also never advise clients to go from Residential right into OP—that type of drop-off in support can cause a severe relapse and does not set clients up for success. I think its important to mention here that access to care can be HUGE barrier for a lot of people. Sometimes insurance companies won’t cover the appropriate level of care, or they will cut off coverage prematurely. These cases are complex, and it is the job of the treatment teams to create a plan that can lead to the best possible outcome for the client.
Jennie: When I am determining if a patient is appropriate for my OP practice, one of the primary characteristics I am looking for is a good foundation of motivation and openness to learning coping skills and applying them. Some ambivalence in any stage of recovery is normal; however, being in OP means less structure and accountability, so an intrinsic drive for recovery is important. When considering eating disorder behaviors, an individual in OP may still be engaging in behaviors but at a lower frequency. In order for a patient to be a good fit for my practice, they need to be open and willing to collaborate with me in their recovery journey.
What do you wish people knew about getting outpatient (OP) therapy for eating disorders?
Edie: One of the hardest parts is starting. Eating disorders thrive off of secrecy and shame. When the eating disorder is talked about, and you are validated by a trained clinical team, the eating disorder has a pretty hard time surviving. It is not a smooth, simple process, it will get uncomfortable, and there will be times when it feels like recovery may not be possible or worth it. I promise you that it is. If you think you may benefit from added support around your eating disorder, please reach out to an eating disorder therapist. You are worth a life free from the confides of your eating disorder!
Jennie: First things first, see a specialist. Eating disorders are highly complex illnesses that require unique therapeutic approaches, of which typically only eating disorder specialists have mastery. Another thing is that there is no such thing as being “sick enough” to need help. Anyone who is struggling in their relationship with food and body is absolutely deserving of help and support. Also, I wish that patients knew that therapy is not about someone telling you what to do, it is about partnering with a therapist who can help you explore the “whys” of your eating disorder and help you develop healthy coping skills that you can use instead of turning to behaviors. However, in OP, the majority of your daily recovery journey lies on your shoulders and so you will be most successful if you feel motivated to pursue recovery independently.
Hey everyone, I really appreciate you reading my blog! Have a wonderful day. :)
If you are struggling to find eating disorder treatment in San Diego, give me a call for your free 15-minute phone consultation at (858) 699-3754, and I will help you get where you need to be!