Which Level of Eating Disorder Treatment Is Right for Me?

From Hospitalization to Outpatient

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Treatment for eating disorders is complex. Treatment commonly involves multiple providers (a medical doctor, psychotherapist, registered dietitian, and psychiatrist, among possible others). And the United States system has a system of levels of care that is distinct to eating disorder treatments.

From most to least intensive, the levels of care are:

  • Medical hospitalization is 24-hour care in a medical hospital. This is typically for people who are not medically stable and need round-the-clock medical monitoring, which may include intravenous fluids, tube feeding, and constant monitoring of vital signs.
  • Residential treatment (RTC) provides 24-hour care for those who are medically stable but require round-the-clock supervision of behaviors and meals.
  • Partial hospitalization (PHP) allows the patient to sleep at home and attend a treatment center during the day. Individuals can attend the program a minimum of five days a week, from six to 11 hours per day. A majority of meals take place at the treatment center, but the patient has some meals at home.
  • Intensive outpatient treatment (IOP) usually includes three hours of programming two to three days a week. At this level of care, the client lives at home and is often able to work or attend school. Usually, one meal or snack per visit is part of the treatment.
  • Outpatient treatment usually consists of individual meetings once or twice a week with a therapist and/or dietitian.

Determining Level of Care

The American Psychiatric Association (APA) developed guidelines in 2006 for the various levels of eating disorder care. (Updated guidelines have been drafted as of February 2022, but have not yet been officially adopted.)

APA Practice Guideline for the Treatment of Patients With Eating Disorders

"In determining a patient’s initial level of care or whether a change to a different level of care is appropriate, it is important to consider the patient’s overall physical condition, psychology, behaviors, and social circumstances rather than simply rely on one or more physical parameters, such as weight."

This is a specific attempt to move past weight being the sole determinant of the level of care, which has often been the case.

The APA provides suggested criteria for each level of care. These criteria include:

  • Medical status
  • Suicidality
  • Weight (as a percentage of healthy body weight)
  • Motivation to recover, including cooperativeness, insight, and ability to control obsessive thoughts
  • Co-occurring disorders, including substance use, depression, and anxiety
  • The need for structure for eating and gaining weight
  • Ability to control compulsive exercising

Ideally, treatment should start with the level of care required to manage symptoms and provide the most effective setting for a successful recovery.

Often, and perhaps ideally, people with severe symptoms begin treatment at higher levels of care and gradually step down to lower levels.

Stepped Care Approach for Eating Disorders

When treatment resources are constrained, many researchers and treating professionals advocate for a “stepped care” approach. This is only appropriate for those who are medically stable.

Using the stepped care approach, healthcare providers try the lowest level of intervention first. If the individual is not improving, they move up to the next higher level of care. With this approach, the lowest level of intervention may be self-help or guided self-help.

However, if an individual is not medically stable, and in cases of anorexia nervosa, treatment should not begin with self-help or guided self-help. The disorder is too severe and patients need professional help to manage it.

Many insurance companies (largely driven by cost containment) have their own guidelines. Each company can dictate the level of treatment to which a patient has access.

Medical Hospitalization

While all of these factors affect decisions about levels of care, there are some indicators that apply to each level.

People may begin or transfer to inpatient care if any of the following are present:

  • Unstable heart rate or blood pressure
  • Significant weight loss and/or food refusal
  • Evidence of malnutrition
  • Inability to stop exercising
  • Need for supervision to eat (including tube feeding)
  • Need for supervision to not purge
  • Lack of treatment options near home
  • Presence of other psychiatric disorders that would require hospitalization
  • Presence of suicidal thoughts with high lethality or intent

If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at 1-800-273-8255 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.

For more mental health resources, see our National Helpline Database.

Residential Treatment

A person entering a residential level of care should be medically stable. They should not need intravenous fluids and tube feedings.

Residential treatment can be an appropriate setting for an individual who needs:

  • A high level of structure and supervision of meals
  • To be prevented from exercise and purging (due to poor to fair motivation to achieve this on their own)
  • Help managing extreme anxiety, other psychiatric problems, and/or insufficient self-control

Partial Hospitalization

At this level, patients should be medically stable. They typically require external structure to eat, gain weight, and prevent purging or exercising.

Individuals at this level of care have some ability to manage behaviors on their own for short periods of time. For example, they might be able to manage on their own overnight. And/or, they have others in their lives who are able to provide at least some support and structure.

Ideally, people at this level of care should live near the treatment center where they are receiving care and should be able to travel back and forth daily.

Intensive Outpatient

People in intensive outpatient treatment need to be medically stable and have some motivation to work on recovery.

At this level, individuals should be able to eat independently at least part of the time, avoid compulsive exercising, and reduce purging. They often benefit from being with others who can provide structure and emotional support.

People receiving intensive outpatient care should live close enough to the treatment facility to travel back and forth several times a week.

Inpatient hospitalization, residential treatment, partial hospitalization, and intensive outpatient treatment are considered higher levels of care (HLC). 

Outpatient

People in outpatient treatment are medically stable and have good motivation. They can manage their own meals, prevent compulsive exercise, and have greatly reduced purging.

At the outpatient level of treatment, an individual has others available to provide emotional support and structure. They should be living close to treatment so they can participate in regular follow-up.

One option is family-based treatment for adolescents. This approach shifts the provision of support, structure, and meals from treatment providers to parents. Under this treatment, adolescents who might otherwise be in residential, PHP, or IOP levels of care can be safely managed at home by their parents.

Recap

While higher levels of care are needed in some cases, people who are motivated and medically stable may be able able to use outpatient treatment options.

A Word From Verywell

Finding the right level of care for your needs is an important part of your journey toward eating disorder recovery. It is important to remember that recovery is a journey. Many people with eating disorders who are in treatment go through various levels of care.

Relapses are normal and part of the process. Try not to become discouraged if you need to take a few steps back before moving forward again.

If you or a loved one are coping with an eating disorder, contact the National Eating Disorders Association (NEDA) Helpline for support at 1-800-931-2237

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5 Sources
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