antibiotics and residential care for eating disorders
There are many reasons for my lack of enthusiasm (and it is that, not a total rejection or wish to make it unavailable). Let me just focus on one, through an analogy that may work for many: residential care is like a super high dose antibiotic that is withheld until the infection is quite severe and then withdrawn before the infection is fully resolved.
Of course we want to make sure people have access to emergency antibiotic care if they have been poorly managed up to that time or have a particularly dangerous strain of infection. But to base a treatment system on that sort of emergency intervention leads to patients not getting the care they need early on when the prognosis is better. If we withdraw the sometimes excellent intervention before it is completed - and it is simply NOT POSSIBLE to stay in residential long enough to do that - and switch to a lower-dose treatment administered by less-trained and often completely cowed people - is there any question why the resistance is greater and patients repeatedly have to start over?
We have created a system - accidentally - where the appropriate dose and length of treatment are rarely available. We are creating treatment resistance, weakening long-term resources, and operating in crisis management as a field. No one meant for this to happen, of course, but it is being held in place by many factors - not least that people who understand the danger of eating disorders fear the withdrawal of those late-stage interventions and feel angry and betrayed by those who question the system.
I do not like being an irritant and hurting people with these questions. I would not do so if I didn't truly believe the system is causing preventable harm - and if I did not have example after example of people who have made the transition in their thinking on this topic. People are starting to speak up about misleading statistics, lack of accountability, and false advertising on the part of some residential care providers. Those people who are speaking up are brave, not traitors, and they care as much about the patients as anyone.
Laura, thanks for resuming discussion about this issue. I don't believe you hurt people with these questions. I'd like to add a few of my own.ReplyDelete
I do refer a handful of people (under 24) to residential treatment centers when I can honestly say that we have little to offer them in our day treatment unit or outpatient program, because they are too ill. We always hope that they will be returned to us as a step-down because I think it is pretty clear that to return someone this ill from residential care to their community without having trained the family and provided good follow-up, dooms them to relapse and to becoming, as you pointed out, "treatment resistant".
An example of this would be a patient I recently sent to a residential facility who has out-of-control type 1 diabetes, purging AN, many many many hospitalizations for DKA (diabetic ketoacidosis) and years of failed psychodynamically oriented treatment. Although we routinely medically stabilize pediatric patients, we have no adult stabilization unit for severe diabetes and could not therefore do it. We referred her to a residential center with the understanding that she would be returned to us as soon as she safely could. After meeting with us her parents have been empowered to take charge to keep her safe and to begin family-based treatment Kartini-style once she has been stabilized medically. We shall see. But the point is, it has been terrifically hard to get the residential treatment center to work collaboratively with us to break the former treatment cycle and to include the parents (against her wishes). The therapists and nutritionists there are still very "she has to want to" oriented and chronically under-estimate her weight restoration goal and hence food needs. BUT, because I can communicate with those in charge at this center and they are motivated to retain my good opinion of their work, we have been able to insist on a different approach. It's far from perfect, but it's a start. In the past local providers--who will be providing the actual critical family-based care-- have not been included in planning for discharge from residential centers, goal weight setting, family involvement etc. And, to be honest, many do not take the time to coordinate the multiple calls involved in such collaboration.
I am hopeful that we can keep this level of care (residential) to a minimum and integrate it into a functional team. But I wonder if it will be possible without calling out the names of those centers who cooperate and those who do not. What do you and your readers think?
I think without integration and coordination between levels of care we are lost. Like giving one dose of antibiotic and being surprised it doesn't "work."ReplyDelete
But WITH that integration and coordination we could be saving lives, families, and making eating disorders a great treatment success story in healthcare!
Unfortunately there is no financial or historical model for this in this field. We could, we should, and we MUST.
As an adolescent (between 13-17 years old) I went through a few several month inpatient stays and a 9 month stint in residential treatment. At the time, as soon as I came out and showed signs of struggle/weight loss, my parents and Tx team were really quick to threaten with more intensive (re: inpatient) care which made my poor anorexic brain think, "well, if I'm going to go IP again, might as well starve." I'm fairly certain my parents (and myself) weren't aware of other treatment models and although residential treatment probably saved my life in a few ways, I feel like I never learned how to EXIST in the real world, I certainly didn't learn how to keep myself healthy long-term and my parents were hardly involved. Now, at 23, I'm in the middle of what has turned into a pretty significant relapse. I've been working well outpatient and I have a lot of motivation to get well although am currently struggling with action (open mouth, insert fork, gain the weight back!). I've considered checking into inpatient to get a jump start on the weight gain, but I'm reluctant because of my previous experience with treatment. I'm comforted by the fact that my team is wise/educated enough to recommend this step with the intention of me continuing the bulk of my recovery work outpatient and their reminders that this time, it would not be a punishment, but a "booster step" in my recovery. Learning to eat and feed myself properly in the "real world" is what I need to do, not learn how to exist in the bubble that is residential treatment (as a disclaimer, I do think the residential Tx center I was at was one of the better treatment experiences I've had). At this point, my parents are less in the picture than they previously were, but they have their ways of supporting me from afar and I'm in the process of building a local meal time support system.ReplyDelete
My point of this (reallyREALLY long and rambling, sorry!) reply is that I agree with you, from experience, whole-heartedly. Certainly there are cases when such care (residential) is necessary, but I think it needs to be followed up by sufficient outpatient (perhaps even intensive outpatient) treatment. Securing this treatment and educating families of patients needs to be as much the responsibility of the residential Tx center as parents. Eating disorders are tricky and parents do not come hard-wired with the knowledge and insight to deal with them, they need to be educated just as much as children who are suffering.
Thanks for being a little more eloquent than I was =P
I don't think it is psychologically healthy to take sufferers out of the general community and expect them to live 24 hours a day with other people who are eating disordered. It merely aggravates the symptoms and it's problematic to mix populations, including adolescent anorexia nervosa patients with adults who suffer from bulimia, for example. Better to give sufferers around-the-clock nursing care at home and in their community if that's needed to keep them safe. For the cost of residential treatment, full-time nurses could be hired. Frisch, Residential Treatment for Eating Disorders, Int. J. of Eat. Disord. 39(5); 434-442 (2006) (average cost per day for residential treatment in U.S. is $956)ReplyDelete