(p. 696) Intensive Outpatient Treatment for Eating Disorders
I am a licensed psychologist in Atlanta, Georgia, who began working with individuals with eating disorders 30 years ago. I received a master’s degree from Georgia State University in 1983 and several years later returned to GSU to earn a doctoral degree. Twenty-two years ago, I developed the Atlanta Center for Eating Disorders (ACE), which offers an intensive outpatient program (IOP) for individuals with eating disorders. This private practice has now grown to three locations, one of which also offers a day treatment program for eating disorders that is accredited by the Commission on Accreditation of Rehabilitation Facilities.
The Niche Practice Activity
As the vast majority of people with eating disorders cannot recover with traditional outpatient psychotherapy, a multidisciplinary team approach is widely recognized as the best practice (Joy et al., 2003). After working for over 30 years with this population, I am convinced that the most effective approach is to gather a team of professionals who specialize with this population and who are willing to work together as a cohesive team. This team generally consists, at a minimum, of a psychotherapist, a physician, and a nutritionist. It is also my experience that although individual therapy is a necessary component of the treatment, group therapy is actually more powerful than individual therapy for this population.
Treatment, therefore, begins with a multilevel assessment process. We conduct a psychological assessment and a nutrition assessment and determine the patient’s medical stability through consultation with internists, family practitioners, or pediatricians. As a result of this assessment, the (p. 697) need for treatment and the optimal level of care are determined. We offer several levels of care through our program. The IOP is the most often recommended and generally consists of nine to 20 hours of therapy per week, including individual, family, nutrition, and group counseling, and one meal group session per day. Day treatment or the partial hospital program (PHP) consists of 20 to 40 hours a week and includes all the above components with two meal group sessions a day. Finally, aftercare, which is basically the same level of care as traditional outpatient therapy, may be recommended for patients if they do not have active eating disorder symptoms, if the symptoms are very mild and do not reach diagnostic criteria, if the symptoms have begun within the previous two months, or as a stepdown from the more intensive levels of treatment. About 15% of the people we assess are determined to be medically unstable and are referred for residential or inpatient treatment.
The accepted treatment for eating disorders involves a multimodal approach (Halmi, 2005, Stein et al., 2012) consisting of multiple psychotherapy modalities: individual, family, nutrition, and group counseling and sessions with a psychiatrist. It’s my experience that a combination of types of groups is most effective. We combine skills groups such as cognitive-behavioral, Acceptance and Commitment Therapy, motivational interviewing, and dialectical behavior experiential groups such as art, yoga, meal groups, and process-oriented groups into the treatment plan.
I spend about 20% of my time conducting initial psychological assessments and about 20% of my time leading therapy groups. At this point in my career, I no longer conduct individual sessions, as I have come to believe that group therapy is more powerful and, for me, more exciting work. However, we have a talented staff of individual therapists providing this component of treatment. The remainder of my time is devoted to training, supervision, writing, and administrative responsibilities.
Developing an Interest and Training in this Niche Activity
I developed my interest in this population quite by accident. In the early 1980s, when I was practicing as a master’s-level therapist, I developed an interest in treating eating disorders. I was working with an individual with bulimia who was also attending a group at a hospital that had a unit for the treatment of eating disorders. In the late 1970s, when eating disorders first became a topic of interest, units for treating eating disorders in hospitals seemed to spring up everywhere. However, by the early 1980s many were beginning to close, probably in part due to overreach and in part due to insufficient understanding of the treatment needs of this population. Such was the case at the hospital where my client was receiving group therapy. As it closed, she told the members of the group that she had a psychotherapist who worked with eating disorders, and approximately six of these individuals called me for psychotherapy. I began to read everything I could find about eating disorders, and I thoroughly enjoyed working with these women. I had heard how difficult it was to treat people with eating disorders, so I thought that I must be very talented.
Then reality began to hit. I was too inexperienced to fully understand that the first women I had treated were in an aftercare group and had already received much therapy before contacting (p. 698) me. As I began working with women who had acute and more serious eating disorders, I decided I needed more training and returned to school for a PhD in psychology. I oriented my doctoral program to learning about eating disorders by using it as the topic whenever I had to write paper or do a project of any kind. As I continued working with people with eating disorders, I became frustrated because it seemed that most of these beautiful, loving, talented women needed more than I could offer them in an outpatient practice—but didn’t need to be hospitalized. When I completed my doctoral training, I opened ACE to provide an IOP for this population. It has been my experience that about 80% of individuals with eating disorders will not recover with traditional psychotherapy alone but also do not need the disruption caused to their lives by inpatient and residential programs.
There is very little in the way of formalized training for this population. The International Eating Disorders Professionals Association provides education and high-level training standards as well as a certification process. The Association of Professionals Treating Eating Disorders is an affiliation of eating disorders specialists based in the San Francisco Bay Area. It provides support and training for clinicians and referrals and direct service for clients. And finally, the Eating Disorders Certificate program at Lewis & Clark University may be the only graduate program in the country devoted to the topic.
Joys and Challenges Related to this Niche Activity
Working with this population is extremely rewarding in that I am working with some of the most caring and talented people I will ever meet. These men and women tend to be more sensitive than the average population (physiological differences) and are, thus, more vulnerable to cultural and familial stressors, but they are also extremely loyal, perceptive, and hard-working. This creates in them much ambivalence about themselves and their place in the world, which, when resolved, produces some of the most dynamic people I have ever met. One of the most rewarding aspects of the group work is to see them support and help each other, what we call the power of the milieu. I see more love expressed in one day at work than I would guess most people see in a month in other types of occupations.
Eating disorders are the most fatal of all mental health disorders, including depression, yet they are so misunderstood (Bulik, 2014). Knowing that we are saving lives and helping to change public opinion is also rewarding beyond words.
Another joy is working together with a team who support each other in a common mission. There is much camaraderie among our team, and we are there to support each other when a patient is not responding to the therapy.
Clinically, the biggest challenge is dealing with what I term pathological ambivalence. I’ve written a book entitled A Clinician’s Guide to Dealing with Pathological Ambivalence (publication in process) where I teach strategies for staying out of the inevitable power struggles that arise when these patients are attempting to recover. Another challenge is the possible medical problems that develop and the need at times to refer patients to medical facilities where their psychological (p. 699) needs may not be well cared for because their medical needs get more aggressive treatment. The other challenges center primarily around working with insurance companies and other administrative tasks involved such as scheduling, charting, and billing.
Business Aspects of this Niche Activity
In most parts of the country, there are very few intensive outpatient programs for patients with eating disorders. It has generally been easy to get referrals to the program since for about 20 years we were the primary option for this level of care in the whole southeastern United States. Marketing directly to psychotherapists, schools, and pediatricians has been the most successful strategy. We also have developed strong relationships with many inpatient and residential programs throughout the area who refer to us for stepdown treatment. I have also developed a talk titled “Common Myths About Eating Disorders” that is on our website (www.eatingdisorders.cc), with the offer to provide speakers for interested groups. Recently, treatment options for eating disorders have been increasing, with a growing number of IOP, PHP, and residential programs being developed. However, outside of major cities there is still a dearth of options.
Approximately 70% of the income received is from third-party payers. About eight years ago ACE was awarded accreditation through the Commission on Accreditation of Rehabilitation Facilities (renewed every three years), which enabled us to contract with all the major insurance companies. This is a great benefit to our patients but requires much administration on our part related to the policies and procedures required and careful monitoring of utilization of services. We had assumed that becoming an in-network provider would result in less management by the insurance companies, but that has not turned out to be the case. Although it varies by company, we have to provide updates every few days to two weeks for continued treatment.
The remaining 30% of the income received is self-pay from noninsured patients, deductibles, or co-pays. We bill monthly for current fees. For patients who have very large deductibles (which seems to be rising), we offer payment plans.
Developing this Niche Activity into a Practice Strategy
Readers who are interested in developing a practice focusing on the treatment of eating disorders should start by connecting with other professionals in their area who are also interested in this population. Putting together a team as described above, developing a peer consultation group, and developing several therapy groups is a great way to get started. Becoming active in national organizations such as International Association of Eating Disorder Professionals and the National Association of Anorexia Nervosa and other Related Disorders can be very helpful and can provide a network of local providers, certification options, and treatment resources. The next step would (p. 700) be to develop a website and begin marketing as described above. I would not recommend trying to treat this population in a solo practice unless you have other components and a team you can work with. As stated before, I became frustrated trying to treat these patients with individual psychotherapy alone as it seemed analogous to taking half an aspirin for a headache; we were going through the motions but it simply wasn’t powerful enough to result in change.
For More Information
These websites are useful: National Eating Disorders Association (www.nationaleatingdisorders.org), National Association for Anorexia and Related Disorders (www.anad.org), International Association of Eating Disorder Professionals (www.iaedp.com), and Academy for Eating Disorders (www.aedweb.org). I also recommend the International Journal of Eating Disorders and Eating Disorders: The Journal of Treatment and Prevention (www.onlinelibrary.wiley.com).
References and Resources
Buchanan, L. P. (in progress). A clinician’s guide to dealing with pathological ambivalence: How to be on your client’s side without taking a side by utilizing ambivalence and side-stepping projections.Find this resource:
Bulik, C. (2014) 9 eating disorders myths busted. Retrieved from http://www.nimh.nih.gov/news/science-news/2014/9-eating-disorders-myths-busted.shtml.
Halmi, K. A. (2005) The multimodal treatment of eating disorders. World Psychiatry, 4(2), 69–73.Find this resource:
Joy, E. A., Wilson, C., & Varechok, S. (2003). The multidisciplinary team approach to the outpatient treatment of disordered eating. Current Sports Medical Report, 2(6), 331–336.Find this resource:
Kaye, W. (2008), Neurobiology of anorexia and bulimia nervosa. Physiology & Behavior, 94(1), 121–135.Find this resource:
Stein, D., Hashomer, T., & Latzer, Y. (2012). Treatment and recovery of eating disorders. New York: Nova Science Publishers.Find this resource:
Yager, J., Devlin, M. J., Halmi, K. A., Herzog, D. B., Mitchell, J. E., Powes, P., & Zerbe, K. J. (2014). Practice guideline for the treatment of patients with eating disorders (3rd ed.). Retrieved from http://psychiatryonline.org/pb/assets/rax/sitewide/practice_guidelines.