Rethinking Residential Treatment: Less is More

I am not a fan of residential treatment for eating disorders as it exists today. I am not aware of any scientific research suggesting that residential treatment is superior to outpatient treatment, with the exception of marketing materials from residential treatment centers (which have an obvious bias and financial incentive). We do know that hospital admissions and stints in residential treatment are poor prognostic factors – patients who remain at home and recover through outpatient treatment are more likely to recover than those who go through residential care. To be sure, the relationship between residential treatment and prognosis may be correlational rather than causal. Patients who are sent away to residential treatment generally have longer duration of illness, greater severity of illness, more psychiatric comorbidity, and a history of unsuccessful outpatient treatment.

There is one recently published randomized controlled trial of outpatient vs. residential treatment. Results of this study demonstrated that adolescents who were randomly assigned to outpatient treatment fared just as well as those who were randomly assigned to residential treatment. Given that outpatient treatment is less expensive and less disruptive to the adolescent’s life, the authors conclude that outpatient treatment is preferable.

I am a firm believer in evidence-based outpatient treatments which keep family members fully informed and actively involved whenever possible. Patients who receive treatment which prioritizes nutritional rehabilitation, weight restoration, and cessation of restricting/bingeing/purging behaviors as the essential first step, are more likely to achieve full recovery in less time. In an ideal situation, a skilled therapist can utilize the strengths and resources of the family and coach them in understanding eating disorders, refeeding their loved one, and interrupting her eating disorder behaviors. Families can also be coached in how to maintain a home environment which is conducive to recovery while their loved one participates in therapy to acquire healthy coping skills, learn how to prevent relapse, and manage any comorbid conditions. This is how the Maudsley Method of Family-Based Treatment works. At this time, the Maudsley method is the only empirically-supported treatment for adolescent anorexia nervosa, and has also been shown to be equally effective in treating adolescent bulimia nervosa. Empirical studies on the use of a modified Maudsley approach in treating young adults with eating disorders have not yet been published. However, anecdotal evidence suggests that many young adults respond favorably to a modified Maudsley approach – even those who have been ill for many years and have had numerous stays in inpatient or residential treatment. And, let’s face it: we don’t really have a good alternative treatment for young adults with anorexia nervosa.

The majority of patients who are treated with Maudsley do achieve and maintain full recovery. Simply put, Maudsley works, and there aren’t any great alternatives. Thus, Maudsley should typically be the first-line treatment, especially for adolescents with anorexia nervosa, and should commence immediately following diagnosis. That being said, Maudsley may not be appropriate in a minority of cases. For example, families who are unable to find evidence-based treatment providers near their home, families in which neither parent has the necessary time or energy due to very demanding careers or caring for other small children, families in which parents cannot agree to Maudsley and refuse to compromise or work together, families in which there is abuse or addiction, or families in which one or both parents suffers from a physical or mental illness which impairs their ability to parent their child effectively.

Despite the promise of the Maudsley Method, it is not necessarily effective or appropriate for all patients (this statement, while often cited by critics of Maudsley, is annoying and virtually meaningless because NO form of treatment for any psychological or medical illness is ever appropriate and effective for 100% of patients. This is not a weakness of a particular treatment method; this is just reality). For the aforementioned reasons, there is, and probably always will be, a need for residential treatment for eating disorders.

Residential treatment for eating disorders, as it exists today, has several benefits and several drawbacks. The benefits include:
• Supported nutrition to promote appropriate weight restoration
• Round-the-clock monitoring to prevent patients from engaging in bingeing, purging, restricting, and substance use
• Protection from self-harm and suicide
• Providing the patient with a respite from the stresses of school, work, sports, and everyday life
• Providing the family with a respite from the daily strain of caring for their loved one

The drawbacks to residential treatment, as it exists today, include:
• Prolonged separation from the family and home environment
• Prolonged absence from school, friends, extracurricular activities, and normal routines
• Exposure to other eating disorder patients, which can result in acquisition of new symptoms, solidification of identity as an “eating disorder patient,” and competitiveness with other patients about who is sicker or thinner
• Artificial environment – a “bubble” – which does not translate to real-world living
• Exposure to outdated and unproven theories about the etiology and treatment of eating disorders (e.g., blaming “family dysfunction,” search for “root causes,” exploration of supposed “underlying issues”)
• Failure to plan adequately for a smooth transition home
• Insufficient family involvement (weekly phone sessions and “family weekend” pay lip service to family involvement, but they often play the blame game, focus on presumed family dysfunction, advise parents to “back off” and not be the “food police,” and fail to educate families as to how to help their loved one recover. In essence, many family sessions send all the wrong messages and fail to send the helpful ones).
• Over-diagnosis of and over-medication for supposed comorbid disorders which are largely, if not entirely, the result of malnourishment and / or refeeding
• Attempts to use psychotherapy of any kind on patients who are not able to benefit cognitively or emotionally.

These last two points are particularly striking to me (granted, these problems occur with less-informed outpatient treatment as well). I have had many patients who were diagnosed with and medicated for severe mental illnesses such as major depression, bipolar disorder, or even borderline personality disorder, while they were underweight or re-feeding in residential treatment. In many patients, these symptoms decrease substantially or disappear altogether once the patient has reached and maintained a healthy body weight for a number of months. I have several patients who arrived at my office after years of ineffective treatment, with multiple psychiatric diagnoses, taking multiple medications. After weight restoration and maintenance along with evidence-based psychological interventions, these patients no longer required medication for any psychiatric symptoms and no longer met criteria for ANY mental disorder. Sometimes, less is more.

What many psychiatrists and other mental health professionals fail to understand is that all people who are malnourished or re-feeding, even those without eating disorders, exhibit symptoms that mimic certain mental disorders (see Minnesota Starvation Study). Diagnoses made while a patient is underweight or re-feeding are often inaccurate. Medicating a patient for a presumed mental illness which is actually the direct result of a malnourished and / or refeeding brain is at best ineffective and at worst quite harmful. Obviously, many patients with eating disorders do have genuine comorbid psychiatric issues, and clearly these need to be identified and treated. But even those patients with legitimate comorbidities may find that their other symptoms are more manageable, or require less medication, when their eating disorder is under control.

Nearly all patients in residential treatment for eating disorders are there because they are significantly malnourished or actively engaging in frequent binge/purge behaviors. These are patients with significant (though temporary) brain damage which renders them unable to process emotions, think rationally, perceive other people’s intentions, or think logically about food, weight, or body image. We know that this brain damage is reversible only after months of full nutrition, weight restoration, and abstinence from eating disorder symptoms. I understand the rationale that, since patients are in residential treatment, they should be given every possible type of treatment available from equine therapy to process groups to CBT to psychoanalysis to making pretty necklaces. I understand that the directors of residential treatment centers want to provide patients with every possible tool for recovery. But what if the patients are not yet equipped to use these tools? And what if some of these tools can be harmful? Again, this may be a case of less is more.

In my ideal world, residential treatment would retain the benefits it currently has while eliminating the drawbacks. Here’s how it would work:
• The immediate focus would be on full nutrition, full time so that patients can restore their weight as quickly as is medically safe and can break the binge/purge cycle (if applicable). This would include three meals and three snacks per day, carefully monitored. “Magic plate” would be employed, and patients would be required to eat 100% of their meals and snacks. There would be no “rewards” for eating well or “punishments” for eating too little. Eating disorder patients are punished enough by their illness, so the last thing they need is a punitive external measure. Rather, there would be no alternative other than to consume full nutrition, preferably through food, but otherwise through a supplement or nasogastric tube.
• Patients would be carefully monitored and prevented from hiding food, bingeing, or purging.
• Patients would be monitored for urges to self-injure or commit suicide and kept safe from any possible means of self-harm.
• No new diagnoses would be made and no new medications prescribed.
• No individual therapy, family therapy, or group therapy of any kind would be provided. However, a psychologist specializing in eating disorders would be available daily to provide supportive counseling for patients who request it.
• Patients would spend their days participating in relaxing, rejuvenating activities such as reading, watching movies, playing board games, getting massages, taking nature walks and practicing gentle yoga (when medically appropriate).
• Patients would be educated about the genetic and neurobiological basis of eating disorders as well as the role of under-nutrition and compulsive exercise in the development and maintenance of these illnesses. They would be provided with scientifically valid information on effective treatments for eating disorders and relapse prevention.
• Through phone conferences and/or in-person sessions, family members would be educated about the genetic and neurobiological basis of eating disorders as well as the role of under-nutrition and compulsive exercise in the development and maintenance of these illnesses. They would be provided with scientifically valid information on effective treatments for eating disorders and skills to help their loved one continue on the path to recovery at home.
• Family members would be provided with daily updates on their loved one’s progress, regardless of the patient’s age. Family members would also be encouraged to contact the treatment center at any time with questions or concerns.
• Family members and friends of the patient would be strongly encouraged to call and visit the patient whenever possible.
• A physician would set an accurate target weight range for each patient, taking into account her pediatric growth charts, weight/build history, and genetics. The target range would represent the patients’ ideal, healthiest weight, not some arbitrary minimum BMI. Research shows that the vast majority of adult patients require a BMI of at least 20 in order to achieve complete physical and mental recovery, so that would be a good starting point.

Patients would be discharged from my ideal treatment facility only after the following criteria were met:
• The patient has achieved 100% of her ideal body weight.
• The patient eats 100% of her meals and snacks with little resistance.
• The patient reports a significant decrease in urges to restrict, binge, or purge.
• The patient is not experiencing suicidal ideation or urges to self-harm.
• The patient expresses readiness for discharge and willingness to work towards recovery.
• The family has been well-educated about eating disorders and feels confident to manage their loved one’s symptoms at home.
• The patient and her family members have collaboratively developed a specific, written outpatient treatment plan. This plan includes referrals for evidence-based psychological treatment for the individual patient and her family as well as regular medical monitoring. In addition, the plan contains specific strategies for dealing with the patient’s eating disorder behaviors and for creating a pro-recovery home environment.

Although it exists only in my imagination, I would predict that a residential treatment center such as the one I described would be more effective than most currently existing treatment centers. It would also be much cheaper, since far fewer staff would be required. Granted, patients may have a longer duration of residential treatment than they do now, since the goal is 100% weight restoration, but patients would be less likely to relapse. Since this treatment center would be cheaper anyway, and patients would be less likely to require repeated admissions, the overall cost to the patient’s family and to society would be much lower.

21 Replies to “Rethinking Residential Treatment: Less is More”

  1. Why don’t you consider starting just such a center? You’ve outlined it very well. You could have a continuum of care with outpatient the priority and a small, intimate inpatient center such as you describe for those that need more support.

  2. Anne,

    I would LOVE to start a center like this. Since I was 17, have had a fantasy of starting an innovative mental health treatment center, although the nature of the fantasy treatment center has evolved over time.

    My concerns with starting a treatment center are: 1.) I don’t know much about starting a business, marketing, budgeting, etc, 2.) I would need a lot of money for start up costs, and 3.) I wouldn’t want my leadership role as founder/creator/administrator or whatever to detract from my clinical work. I am a clinician through and through, and I don’t think I have the training or skills or desire to do hiring and firing and marketing and insurance negotiations, etc.

    It is still a possibility for the future, though, and thanks for the suggestion!

  3. I was going to ask the same question anne asked. I really love the idea of getting massages. If I could get massages everyday, I would totally go to a treatment center.

    Here’s my question, much of what you wrote about has to do with adolescents getting treatment. I know I’ve touched on this before, but if you don’t think a residential center is a good place to be, what would you suggest for adults with EDs, who live on there own and aren’t going to eat meals and snacks on their own free will.

    You really believe that someone needs to be at 100% of their ideal body weight? I can’t even fathom that one. I don’t like that one bit. (the idea of it, not what you have to say).

  4. Although I know this post is geared more toward adolescents and treatment, as an adult attempting to recover from anorexia nervosa who recently completed a PHP program with a residential component (we were in program five days a week and stayed there at night) I have to say I agree with you 100 percent! Yes, I did gain some weight but that is about all I can say the program did for me (I actually left feeling worse about myself and my chances of recovery than when I started!)

    It used a DBT approach which did not seem to fit very well, and I saw several patients who had completed four months or more of the program either relapse very early after discharge or return for “booster” treatment.

    My doctor/therapist are now working on continued recovery, including bringing a dietician on board to help me with meal planning and healthy eating for both weight restoration and then maintenance.

    Thanks for having the courage to say what many professionals will not – PHP/residential treatment does in fact reinforce the eating disorder identity and does not take into account the many factors you listed that account for difficulties for patients to recover in these settings, particularly the fact that many patients are basically starving upon entering treatment!

  5. Ptc,

    I think the best place for an ED patient of any age to recover is at home, with the love and support of family members, medical monitoring, and a therapist who practices evidence based treatment. That said, there are some adults who don’t have family members who are capable of or willing to provide the meal support and emotional support necessary for recovery. For these people, residential treatment may be the only way to recover.

    I completely understand your resistance to restoring your ideal body weight. I’m sure the tremendous fear of being at a healthy weight is completely overwhelming. Please know that this fear and resistance is a symptom of your illness which is not rational, and which goes away once you are recovered. There is very clear scientific evidence that patients who reach and maintain 100 percent of their ideal body weight are much more likely to achieve full and lasting recovery, free of the horrible ED thoughts and behaviors. I believe that allowing a patient to remain even slightly below her IBW is cruel, and is a recipe for a lifetime of EDs.

  6. Angela,

    Best of luck in your continued recovery. Your Residential treatment experience may have been less than optimal, but thankfully it helped restore your nutritional stability and physical health. Now your brain is in a much better place to benefit from psychological treatment.

  7. Yeah, there’s no way I’d ever move back home with my parents so they could feed me. I love my parents to death and I see them once a week, but I wouldn’t do that. I don’t think I need to anyway. Yes, I don’t eat 3 meals and 3 snacks a day, but I don’t need someone to make sure I eat all of the time.

    Why is it so important to be at 100% of your IBW? I would be completely huge if gained that amount of weight. According to “the charts,” I’d have to gain 16-17 lbs to be at 100%, which is nuts because my weight is not unhealthy right now. No one would look at me and think “oh, she looks sick.” I know part of my perception may be off, but I know for sure that no one is thinking that I look underweight/sick. I’m small (just under 5’1″) so I’m supposed to be the size I am. If I gained weight I would look and feel so gross. I can notice and feel 2 pounds on me, and I’m sure everyone else can too.

    It’s just hard. I know I should eat more than I do, but then I also feel like, “Well, I don’t need it.” I am totally fine eating when I’m hungry, but if I’m not hungry I don’t see any reason to eat and don’t want to eat.

    Sorry for rambling about nothing.

  8. PTC
    Two things (and I’m sure Dr. Ravin can address this more in-depth than me): ideal body weight isn’t necessarily what the charts say, otherwise I could stop weight restoration right now because I am at the low end of what most charts say is the weight range for my height and bone structure. That doesn’t mean I’m at a healthy weight; my IBW as decided by my doctor (who specializes in eating disorders) is somewhat higher than what most charts say. Second, it is my understanding that reaching your full IBW is crucial in recovery because it helps reduce restricting, bingeing/purging and other eating disorder symptoms. I might like to be at a lower weight, but that’s also when I tend to struggle with eating disorder thoughts and behaviors.

    I find in my own experience I can’t rely on hunger cues, because most of the time I simply don’t feel hungry and I could go almost all day without eating at this point. I hope someday my body will again naturally feel hunger and I won’t have to eat on a schedule – but until then, that’s what I will do to continue with recovery.

    Dr. Ravin,
    Thanks for your words of support. Just one final thought – I also saw many patients on a lot of medications while in PHP and was pressured to consider going on medications which my regular doctor/therapist (who specializes in eating disorders and has seen me for almost two years) does not feel I need (he likes to say food is my medicine .) This push toward what I see as overmedicating of patients with eating disorders frankly frightens me and it seems to be a growing trend. I’m not saying medication can’t be useful in treatment, but when I see people taking six to seven psychotropic medications, it causes me to question the treatment.

  9. Hey Angela,

    I’m glad that you know what you have to do in order to make your way to recovery…and that you stick to it. That takes a lot of discipline and hard work, so I applaud you for that.

    I know everyone is different when it comes to weight and stuff, and I actually believe that BMI is a bunch of crap, so I never go by that, but here is the link to the chart that I looked it. It’s the one my therapist and all of the ED professionals she works with use.

  10. PTC,

    You are right that BMI is “a bunch of crap.” Frankly, so is any weight chart. Statistical norms say nothing about the proper healthy weight for any given person. Angela is correct in saying that IBW is highly individualized. You can’t always tell by looking whether a person is at their IBW. A healthy weight for one person may be very underweight for another person and too heavy for a third person. One of the most pervasive mistakes in ED treatment is setting goal weight too low. The minimum “ideal” BMI on the charts is 18.5, but the vast majority of ED patients need a BMI of 20 or 21 in order to achieve full mental and physical recovery, and some people need a BMI higher than that to recover. Your IBW should be set by a physician who is knowledgable about the new science on EDs, who can look at your pediatric growth charts, build, genetics, and weight history and arrive at an ideal weight range for you.

    I share your concern about overmedicating ED patients, and I agree wholeheartedly with your Dr that food is the best medicine. Some patients do need medication to treat comorbid conditions, but most patients could thrive on far less medication, if any is needed at all, if they were well nourished and weight restored and provided with evidence based psychological treatments.

  11. I agree with the vast majority of the post although I do hope that in the ideal future when your residential program is up and running there will also be half-way houses and respite care places where whole families can come and learn and heal together as well as outreach teams who will go into patients’ own homes to support families in the difficult process of re-feeding.

    I understand the rationale behind not giving out diagnoses and medications before weight restoration but I do think that these statements can be slightly contradictory
    “• Patients would be monitored for urges to self-injure or commit suicide and kept safe from any possible means of self-harm.” and
    “• No new diagnoses would be made and no new medications prescribed.”
    Medication can sometimes help in situations where self-harm is a problem.

  12. Thank you for that explanation, Dr. Ravin. I never really thought of that. I’ve never weighed what the chart says is my IBW so I’m guessing no doctor would ever tell me that that’s what I should weigh. Considering that I stopped growing when I was in 6th grade, there wasn’t ever much growth on my growth chart :), therefore I know they wouldn’t want me to gain 16 pounds. Thank you for clearing that up.

  13. Fiona,

    I agree that families should be able to come to treatment centers to learn and become fully involved with their loved one’s treatment. In my opinion, separation from family is one of the greatest detriments of residential treatment as it exists now.

    I don’t think my statements about 1.) keeping patients safe from self harm and 2.) no new diagnoses or medications are mutually exclusive. I understand that medication can be helpful in reducing or eliminating the urge to self-harm. That said, I believe that medication should be used only when clearly necessary. Many patients can be prevented from self-harming if they are kept in a safe environment and not given access to sharps or pills or other means of self-harm.

  14. PTC,

    I’m glad my explanation made sense to you. If you stopped growing in 6th grade, your height and weight will probably be well below statistical averages. If you developed your ED several years after you stopped growing and years after you started menstruating, your IBW would probably be similar to your pre-ED weight, plus 5-10 pounds to account for the natural growth and development that occurs from adolescence to adulthood.

    I wonder if learning this makes you more willing to shoot for full recovery?

  15. I agree that over medication is wrong, and I’m sure in an environment like your idea treatment centre it wouldn’t be necessary.
    I suppose I’m just grouchy and guilty because I know that all of your points are right – it’s just that, on my own, without the backing of this ideal inpatient (because it doesn’t yet exist) I failed to be able either to refeed or to keep my daughter from self-harm.

    Family Based Treatment is the ideal and should always be used as the first line of treatment, but it does need to come with a plan B and a generous amount of back up, so if you’re not going to start this new treatment centre I hope someone does soon for all those whose families can’t do FBT without support for whatever reason.

    If you don’t want to run it would you consider being clinical advisor?

  16. Hmm, again interesting info. Let’s see (I’m thinking aloud here), I stopped growing at when I was about 12 (6th grade), and I’m not sure what I weighed at that time, the weird eating stuff started my freshman year in high school, right around the age of 15 and I weigh less now than I did then, but not by much, maybe like 5-7 pounds. Then when I really started “restricting” I obviously weighed less than I do now, but I was also younger too, so that might make a difference. I guess knowing that my IBW probably would not be 115 makes me feel better because there is no way that I need to weigh that or would ever let that happen. So, from what I get from your info, no doctor would want me to get to that weight, and that makes me feel better. So, learning that helps, but the thought of gaining any weight still freaks me out. I feel like I just can’t do it.

    Thank you for answering my questions…and answering them so well!! 🙂

  17. Pretty nice post. I just stumbled upon your blog and wanted to say that I have really enjoyed browsing your blog posts. In any case I’ll be subscribing to your feed and I hope you write again soon!

  18. Great post. Fascinating comments.

    I share your dream of the ideal residential treatment, and Fiona’s hope that there be step-down (and step-up) during transition between there and home.

    I see NO REASON why this center would be different for young patients and adults and it perplexes me why people think it would.

    PTC, of course you have to reach your body’s normal, optimal body composition to recover. You know that being below that is holding you in ED thoughts and behaviors and keeping you from achieving the insight you need to stay well. The idea that you would be “huge” at a normal weight is something the malnourished brain does to people. We need to let doctors set the targets, nutritionists help us get there, and therapists teach us how to get there and stay there. ED doesn’t like any of the above and should not, in my opinion, get a vote!

  19. I guess I side with the E.D. on this one because I feel like I could lose a couple of pounds, so gaining them is definitely out of the question. I will freak out when I weigh myself, if I have gained weight.

  20. We should all try and follow something like this, it’s a great idea, I just hope it works out for all of us. The problem is, willpower. I’m actually very lazy so I’m always looking for ways to find someone else to do it but in this particular case I can’t actually get someone to do it for me 😛

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