Which Level of Eating Disorder Treatment Is Right for Me?

From Hospitalization to Outpatient

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Treatment for eating disorders is complex. Not only does treatment commonly involve multiple providers (a medical doctor, psychotherapist, registered dietitian nutritionist, and psychiatrist, among possible others), but the United States system has a system of levels of care that is distinct to eating disorders.

The levels of care ranked from most- to least-intensive are as follows:

  • Medical hospitalization is 24-hour care in a medical hospital. This is typically for patients who are not medically stable and need round-the-clock medical monitoring, which can include intravenous fluids, tube feeds, 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 for times usually ranging 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 for 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 treatment.
  • Outpatient treatment usually consists of individual meetings once or twice a week with a therapist and/or dietitian.

The American Psychiatric Association (APA) developed guidelines for the various levels of care. The APA guidelines state:

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 stepped level of care. These criteria include the following factors:

  • 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
  • Structure is needed for eating and gaining weight
  • Ability to control compulsive exercising

Many considerations are necessary to determine the right treatment level for an individual. Treatment should ideally start with the level of care required to manage symptoms and provide the most effective treatment setting for a successful recovery.

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

On the other hand, when treatment resources are constrained, many researchers and treating professionals advocate for a “stepped care” approach for those who are medically stable.

Using the stepped care approach, the lowest level of intervention is tried first and if patients are not improving they are stepped 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. Professional help is needed to manage the severity of the disorder.

Finally, 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.

While all of the previously cited factors—as well as the availability of treatment and insurance—need to be considered, there are general indicators for the various levels of care.

Medical Hospitalization

Patients may begin treatment or transfer to inpatient 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

A person entering a residential level of care should be medically stable so that intravenous fluids and tube feedings are not needed.

Though they do not need round-the-clock care, residential treatment can be an appropriate setting for an individual who needs:

  • A high level of structure and supervision of meals
  • Prevention of exercise and purging due to poor to fair motivation
  • Help managing extreme anxiety, other psychiatric problems, and/or inability to self-control

Partial Hospitalization

Patients should be medically stable at this level, though they will 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, patients should live near the treatment center where they are receiving care, and should be able to travel back and forth daily.

Intensive Outpatient

Patients 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, prevent compulsive exercising, and reduce purging. They often benefit from being with having others who can provide structure and emotional support.

Individuals receiving intensive outpatient care should live close enough to where they are receiving treatment to travel back and forth several times a week.

Outpatient

Patients 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.

Family-Based Treatment for Adolescents shifts the provision of support, structure, and meals from treatment providers to an individual's 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.

Recovery is a journey. Many patients 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.

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  • American Psychiatric Association. American Psychiatric Association Practice Guidelines for the treatment of psychiatric disorders: compendium 2006. American Psychiatric Pub, 2006.