The treatment of eating disorder clients in a community-based partial hospitalization program. .

The provision of psychological treatment within the community is becoming increasingly important as time and resources become more scarce. Nowhere is this challenge greater than when undertaking the treatment of eating disorder clients in a community mental health setting. In this paper, we outline a multi-faceted treatment approach to eating disorders within a partial hospital program that is affiliated with a community mental health hospital. Although empirical confirmation is not currently available, initial clinical impressions indicate that the program is facilitating the recovery of these difficult-to-treat individuals.

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Practitioners working in community mental health settings are finding an increasing number of clients who present with eating disorder symptoms (Hoek, 1995). These clients may exhibit a wide variety of symptom constellations (Brownell & Fairburn, 1995; Garner & Garfinkel, 1997; Hsu, 1990), including concomitant medical complications (Mehler & Andersen, 1999; Mitchell, Pomeroy, & Adson, 1997; Powers, 1997), comorbid psychological conditions (Edelstein & Yager, 1992; Strober & Katz, 1988), personality disorders(Swift & Wonderlich, 1988; Wonderlich & Mitchell, 1992), impulse and substance abuse problems (Johnson & Connors, 1987; Mitchell, Pyle, Specker, & Hanson, 1992), and self-injury as well as pathology related to sexual abuse (Levenkron, 1998; Schwartz & Cohn, 1996; Vanderlinden & Vandereycken, 1997). In addition, evidence suggests that in a number of weight-tolerant cultures (Garner, 1997), eating disorders are increasing in prevalence among children and adolescents (Lask & Bryant-Waugh, 2000) as well as males (Andersen, Cohn, & Holbrook, 2000). Given these findings, clinicians are often faced with the provision of services to profoundly psychologically and physically debilitated individuals (Levitt, 1998, 2000a, 2000b).

Eating disorder clients generally require intensive and often extensive treatment in order to return to effective functioning. These clients access and utilize multiple services in community mental health settings, including outpatient treatment and hospitalization. Yet, treatment services must be delivered more effectively and efficiently than before due to limited resources (Levitt, 1998) and must be therapeutic, grounded on practice guidelines (Hayes, 1999), and evidence-based (Wade, 1999). As a result, the need for well-executed and sequenced treatment has become essential (Garner & Needleman, 1997).

To complicate the delivery of services, changes in availability of levels of care in community mental health settings have also occurred, with hospital services perhaps being most affected. Inpatient hospitalizations are generally limited to several days and utilized only for purposes of acute stabilization. When achieved, the patient is transitioned to a less intensive level of care such as partial hospital or outpatient treatment. For eating disorder clients, crisis intervention often only serves to intervene with the most deleterious effects of the disorder, not to directly address eating disorder pathology. Unfortunately, many eating disorder clients exhibit an acute-chronic (i.e., intractable) pattern (Yager, 1995), and brief inpatient stays are unable to effectively stabilize symptoms. As a result, partial hospitalization programs for these clients have become increasingly utilized (Kaplan & Olmsted, 1997). Partial hospital programs may be the preferred setting for the treatment of eating disorder clients because they are a less expensive means for providing various services to potentially difficult-to-treat individuals (Kaplan & Olmsted 1997; Kaplan & Spivak, 1996; Levitt, 1993). In these programs, clients attend the partial hospitalization program during the day for a varying number of days and spend nights at home. The managed care review criteria that are utilized for inpatient treatment programs often extend to partial hospitalization programs.

However, practitioners in community-based partial hospitalization programs are faced with two major hurdles: (a) incorporating best-practice models of treatment and (b) evaluating the outcomes of those treatments. The literature on the treatment of eating disorders supports the utilization of a multi-dimensional perspective (Garfinkel, 1996; Garfinkel & Garner, 1982) with an emphasis on empirically confirmed interventions such as cognitive-behavioral approaches (Fairburn, 1997; Garner, Vitousek, & Pike, 1997; Johnson & Connors, 1987), psycho-educational and nutritional approaches (Beaumont & Touyz, 1995; Garner, 1997; Weiss, Katzman, & Wolchik, 1985), family therapy (Honig, 2000; Minuchin, Rosman, & Baker, 1978), and interpersonal psychotherapy (Fairburn, 1997). It is also recommended that interventions be tailored and sequentially implemented on an individual basis (Andersen, 1985; Garner & Needleman, 1997).

With regard to evaluating treatment outcome, clinicians face significant obstacles. As examples, clients rapidly enter and leave treatment, often present with multiple Axis I and II diagnoses, and frequently terminate treatment prematurely, thus making outcome evaluation difficult. In addition, treatment providers are often the same individuals who must evaluate the outcomes of services (i.e., dual roles). Outcome evaluation requires tools that are valid, brief, focused, easy to administer, inexpensive, and can serve multiple purposes (i.e., assessment of acute clinical status as well as function as a legitimate outcome measure). These brief, easily repeatable, and clinically useful measures have been previously described as Rapid Assessment Instruments (RAIs; Fortune & Reid, 1999; Levitt & Reid, 1981). For examples of RAIs, the reader is referred to Fischer and Corcoran (1994a, 1994b). We now review a treatment approach to eating disorder clients in a community-based partial hospital setting.

TREATMENT APPROACH

Program Overview

The Eating Disorders Program (EDP) partial hospitalization program presented here represents one of several psychiatric services provided at a nonprofit community-based hospital located in a large, urban, Midwestern city. Clients access the EDP via referral by self, managed care companies, professionals, family members, or friends. Most have some form of healthcare coverage, and a small number receive scholarships through the hospital's mission to support the community. Approximately 15% transfer from inpatient services (i.e., most clients are directly admitted to the EDP partial hospital program). Exclusion criteria for admission include medical instability, overt suicidality, psychosis, severe cognitive impairment, and significant symptoms of chemical dependency.

Treatment Philosophy

The EDP views clients' symptoms as learned behaviors that are maintained by multiple psychological, social, familial, and biological factors; all intertwined within a culture that reinforces many of the values of these clients such as fear of fatness, intense focus on dieting and weight loss, the belief that improved self-esteem can be obtained through weight loss, and so forth. In addition, eating disorder behaviors are considered to be functionally adaptive for these clients. In this regard, symptoms may function to manage uncomfortable emotions such as excessive arousal, discomfort, fear, anger, social anxiety, and/or avoidance. Clients may also experience reinforcement of symptoms by increasing self-worth through weight loss (Brownell & Fairburn, 1995; Garner & Garfinkel, 1997).

Based upon the preceding, the goals of the EDP are to: (a) interrupt the most deleterious aspects of the eating disorder; (b) normalize eating patterns; (c) identify and intervene with behaviors that perpetuate the eating disorder (e.g., chemical dependency, partner abuse, self-injury, shoplifting, stealing); (d) enhance client functioning by teaching alternative ways of self-regulating; and (e) facilitate the development of a secure and supportive outpatient environment through support groups, family and peer education and support, and outpatient care.

COMPONENTS OF THE EDP TREATMENT

The following program description is a brief overview of the EDP components that we have found therapeutic within a community-based treatment setting. Clinicians, however, may need to familiarize themselves with the clinical complexities often encountered when providing treatment to eating disorder clients in partial hospital settings (Anderson 1985; Brownell & Fairburn, 1995; Brownell & Foreyt, 1986; Garner & Garfinkel, 1997).

Orientation of Clients

Orientation to the EDP begins as soon as the client calls for an assessment or requests general information about the program. The process of orienting clients continues through the admission procedures to the point where the client actually meets the EDP staff and enters the program. At entry, clients are often confused, anxious, fearful, and physically and psychologically debilitated. An EDP staff member meets with the client and, with written materials, explains the program schedule and expectations of participants such as program participation, weight restoration, and requirements for physical and laboratory assessment. The orientation includes a facility tour and introduction to the other clients and staff. Finally, after encouraging the client to ask questions, express concerns, or indicate any special or unique needs, a treatment contract is presented. The treatment contract specifies expectations of the client as well as consequences for noncompliance. The client and a staff member sign it and the client is provided with a copy.

Assessment and Evaluation

Each patient is initially assessed in a variety of areas including medical status, eating disorder symptoms, and associated psychological problems (i.e., depression, anxiety, thought disturbance). Through surveys, clients are asked to provide self-report information in a number of areas including a relatively detailed past-to-recent history of their eating disorder, attempts at recovery, and successes and difficulties in attempting to modify eating disorder behaviors. Clients also complete a number of self-report measures relating to anxiety, depression, hopelessness, and eating behaviors (Levitt, 1992) as well as RAIs (Fortune & Reid, 1999; Levitt & Reid, 1981).

All clients receive a nursing assessment as well as a physical examination from their primary care physician, who is provided with a detailed form that ensures consistency with medical evaluations across clients. Clients also receive a psychiatric evaluation that explores comorbid psychiatric disorders, safety status, the psychiatric effects of other related physical problems, and psychotropic medication needs. The psychiatrist longitudinally monitors the client's emotional well-being, manages psychotropic medications, participates in the formulation of the treatment plan, and provides consultation regarding ongoing treatment decisions.

Families are routinely integrated into the program. The family evaluation explores their understanding of the eating disorder, its impact on members, past and present interactions with the client about eating disorder behavior, and the family's goals for treatment.

The evaluation also includes an assessment of the client's motivation for, and willingness to, change. Motivation is estimated by examining the eating disorder pathology and its effects on the client and the client's overall skill base, support system, and acknowledged motivation for change. This information is used to focus the treatment on the client's current stage of change (Miller & Rollnick, 1991).

Observing the client's behaviors and interactions within the program itself is vital. Interactions with staff, other clients, and family members give context and meaning to all of the other previously collected information. Through observation of changes in the client's behaviors, along with changes in other self-report measures, the efficacy of treatment is ascertained.

All information is organized into a global picture of the client, around which a treatment plan is designed. Because most treatment frames are of short duration, goals need to be highly specific, concrete, observable, and achievable. The treatment plan specifies these goals and identifies specific interventions. The treatment plan is re-evaluated during weekly staff meetings and is regularly reviewed with the patient for consent.

Treatment

Based upon a literature search of standard and effective treatments for individuals with eating disorders, the EDP developed a best-practice model. The EDP is essentially a group-based intervention that enables (a) information to be efficiently imparted, (b) problem-solving, and (c) a social laboratory within which to practice new behaviors. Clients eat and essentially remain together throughout the day. This model focuses on therapeutic relationships, clinical experience, and the contextual requirements of the treatment itself (i.e., short duration, community-based focus, group-based approach, freedom to not comply or terminate treatment). The approach of the treatment team includes: (a) a nonblaming, nonjudgmental stance; (b) provision of information and guidance to enhance the client's motivation for change (i.e., clients are given data based on observations of their behaviors and encouraged to become students of themselves and to self-observe); (c) encouragement to use the program and homework assignments as opportunities to practice new skills, process mistakes, and develop new learning (i.e., to challenge themes of perfectionism, excessive control, low self-esteem, over-compliance); and (d) provision of a climate conducive to self-change (i.e., to empower the client to evaluate options, take risks, and reinforce themselves for tackling challenges). Family therapy incorporates these themes as well.

Clients are given a nutritional assessment, meal plan, meal card, and food log. Each is weighed daily by staff, eats two meals per day in the EDP, and receives staff feedback regarding food intake. Staff also provides encouragement, nutritional suggestions, and additional nutritional supplements if necessary. The dietician provides group nutritional education before, during, and after meals. Food logs confirm food eaten at home during the evenings or on weekends and are reviewed daily. Based on food logs, weight status, and in-program nutritional behaviors, obstacles are examined, and assignments--focused on generating new solutions--are given.

Clients are taught about eating disorders (e.g., psychological and biological effects of starvation and purging) and the role the disorder has played in their lives, including negative effects on health and social and family relationships. Clients are given exercises to begin to picture a life without an eating disorder. Group feedback is extremely important, and most confrontation as well as support comes directly from other group members. Staff guards against the idealization of the eating disorder experience, as the goal for clients is to begin to identify eating disorder consequences in an effort to increase motivation for change.

An extremely important part of treatment is to provide an opportunity for clients to identify their own body experiences more accurately (e.g., size and proportion, body image, relation to others). Art, music, and movement therapies are used in this process. For example, clients estimate body size during art therapy and compare this with their actual body size, which is traced onto paper; tai chi exercises increase body awareness; and experiencing one's body in motion during movement therapy develops an improved awareness of the spatial feel of the body self. Utilizing psycho-education--and art, movement, and music therapies--clients begin to identify enteroceptive cues such as hunger, satiety, fatigue, anxiety, and so forth. For many, identifying internal experiences is difficult (Bruch, 1973).

Illogical thoughts and behaviors related to eating disorder pathology may be nutrition-related as well as either primary or secondary to the eating disorder itself. Cognitive therapy is designed to help clients identify erroneous thinking styles and to develop skills to challenge these faulty thoughts and beliefs. This process entails identifying the thoughts and consequences that ensue from faulty thinking and developing alternative responses that may lead to effective thinking and behaving (Garner et al., 1997; Wilson, Fairburn, & Agras, 1997).

Clients receive education and training in a variety of skills that address deficits that are associated with eating disorder pathology (e.g., difficulties with problem-solving, social relationships, and managing affective arousal). An integrated skills-based approach (Levitt, 1998, 2000a; Linehan, 1993) is taught in group format. For example, clients are taught a basic problem-solving paradigm that they may use in any given situation. Clients are asked to generate a number of challenging experiences in which they had difficulty generating effective solutions that did not rely on the eating disorder. Through small client dyads and triads as well as large group discussion, participants learn to use more effective problem-solving skills. Relationships are often challenging for eating disorder patients (Hsu, 1990). Effective relationship management includes the teaching of assertiveness training as well as effective communication skills. An enhanced ability to manage social demands may result in less reliance on the eating disorder as a way of managing life situations (Hsu; Linehan). Again, skills are taught and practiced within the group format. Relaxation therapy is a skill that may be used whenever anxiety or fear increases to the point that other responses, such as relationship skills or problem-solving, are impeded. Relaxation therapy lends itself well to a group format, and both imagery and breathing techniques are taught as well the ability to elicit a relaxation response as efficiently as possible, whenever necessary (Polivy & Fenderoff, 1997).

PROGRAM EVALUATION 

Treatment programs are under increasing pressure to evaluate the efficacy of their services (Lyons, Howard, O'Mahoney, & Lish 1997; Wade, 1999), and there are many possible facets to evaluate. We currently employ instruments that are relatively unobtrusive in a community-based setting, provide rapid feedback regarding the severity of clients' conditions, and are practical in assessing improvement. We selected these measures from a larger group described as Rapid Assessment Instruments (Fortune & Reid, 1999; Levitt & Reid, 1981). RAIs are characterized by cut-off scores, which provide an efficient and rapid means of determining whether a client's symptoms represent a clinically significant level of symptom severity compared to a general population (Fortune & Reid, 1999; Levitt & Reid).

Upon admission to the EDP, clients are given a packet of four measures to complete. These same measures are administered at discharge. The Eating Attitudes Test-26 (EAT-26; Garner, Olmsted, Bohr, & Garfinkel, 1982), which is a shorter version of the Eating Attitudes Test (Garner & Garfinkel, 1979), is a brief, 26-item screening instrument that explores general eating pathology, using a Likert-scale for response options. Examples of items include, "Am terrified about being overweight, Avoid eating when I am hungry," and "Find myself preoccupied with food." The EAT-26 correlates significantly with the parent measure, the EAT (Berland, Thompson, & Linton, 1986). The cut-off score is 20.

The Beck Depression Inventory (BDI; Beck, 1967) is a 21-item, multiple-choice measure that assesses current depressive symptoms. This measure explores depressive symptoms such as sadness, pessimism, sense of failure, dissatisfaction, guilt, and expectation of punishment. The BDI appears to be a reliable and valid measure of depression (Katz, Katz, & Shaw, 1999). The cut-off score is 19. The Beck Hopelessness Scale (BHS; Beck, Weissman, Lester, & Trexler, 1974) is a 20-item measure that assesses hopelessness. This measure has reasonable reliability and validity (Katz et al.) and has a cut-off score of 9.

The last measure is the Dissociation Questionnaire (DIS-Q; Vanderlinden & Vandereycken, 1997), a 63-item measure that explores trauma-related (dissociative) symptomatology, which is often associated with psychological, sexual, and/or physical trauma. There are four subscales (identity confusion, loss of control, amnesia, absorption), each with a cut-off score of 2.5, which is the same cut-off for the total score. Each item is preceded by the statement, "To what extent does the following statement apply to you," and has five Likert-style response options. Sample items include, "At times I have the feeling that I am dreaming, I regularly have the feeling that everything is unreal," and "At times it appears that I have lost contact with my body." The DIS-Q appears to be a consistent and valid measure of dissociation (Santonastaso, Favaro, Olivotto, & Friederici, 1997), and high scores are associated with traumatic experiences in childhood (Vanderlinden, Vandereycken, & Probst, 1995; Vanderlinden, Vandereycken, Van Dyck, & Vertommen, 1993).

These four measures enable clinicians in community-based programs to easily and quickly assess, at admission, clinically significant eating disorder and depressive symptoms including hopelessness, and symptoms associated with abuse or trauma, and to re-assess the status of the same symptomatology at discharge. Based upon our preliminary impressions using these measures, clients appear to experience meaningful improvement. Further collection of data and subsequent analysis will hopefully confirm these initial impressions.

CONCLUSION

In this paper, we describe one approach for the treatment of eating disorder clients in a community-based, partial hospital EDP, including the use of assessment and outcome measures. The repetitious use of the adjective, community-based, throughout this article is no accident. It is intended to reinforce with clinicians the practical realities of developing treatment programs that function within the community environment. This environment is plagued with reimbursement issues, monitoring agencies, and complex client needs. We wish to emphasize that it is possible to undertake effective programming and evaluation in this complex treatment environment and encourage clinicians to continue to develop and assess various forms of interventions--not just for eating disorder clients, but for all of our troubled clients.

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John L. Levitt, Ph.D., is the director of the Eating Disorders Program at Alexian Brothers Behavioral Health Hospital in Hoffman Estates, IL. Randy A. Sansone, M.D., is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, OH, and director of Psychiatry Education at Kettering Medical Center in Kettering, OH.