Eating Disorder Treatment Levels of Care Explained (September 2021)

By Margot Rittenhouse, MS, LPC, NCC

The realm of eating disorder treatment, advocacy, and recovery is one that eludes most people until they are in it.

When you, or a loved one, find themselves in this “world,” many questions arise and the most important of these is often “how is this disorder treated?”

The answer is often complicated depending on who is being asked and the individual needing treatment.

Before considering what theoretical ideology would best treat an individual’s eating disorder, the level of care that they require needs to be determined.

Levels of care for eating disorder diagnoses range from medical stabilization in most severe cases to several levels of outpatient including Residential Treatment Centers (RTC), Partial Hospitalization (PHP), Intensive Outpatient (IOP), and Outpatient (OP).

Understanding the role of each level of care can help you and your loved ones navigate this journey.

Medical Stabilization (AKA Inpatient Hospitalization)

As mentioned above, medical stabilization, also known as inpatient hospitalization, is the level of care appropriate for those with severe eating disorders.

These individuals are deemed not medically stable and need the 24-hour medical care that only an eating disorder hospital can provide such as managing the refeeding process to avoid or minimize the dangerous effects of refeeding syndrome, intravenous fluids, regular laboratory testing, and monitoring of vital signs and cardiorespiratory systems.

Individuals in this level of care are also evaluated to determine if feeding by tube is necessary, which occurs when an individual cannot work on nutritional rehabilitation by mouth. This is not the preferred way of nutritionally rehabilitating the patient and is becoming less common but does still occur in the most extreme circumstances.

It is preferred for nutritional rehabilitation to occur via the Dietitian in the eating disorder treatment center.

The goal of medical stabilization is to treat any medical conditions so that an individual can safely progress to the next level of care in their treatment.

Those that need medical stabilization must also be constantly monitored during all meals as they find it incredibly difficult to stop themselves from engaging in eating disorder behaviors. This monitoring is done by mental health workers, nurses, nursing aids, and even therapists at times.

Medical stabilization often takes place in a psychiatric facility or psychiatric wing of a hospital if it is not a designated mental stabilization program.

The limitations on individuals in this level of care are stringent yet necessary, as those deemed appropriate for medical stabilization are often experiencing severe physical ramifications of their eating disorder that could lead to permanent medical issues and even death.

Residential Treatment Centers

Residential treatment centers (RTC) are the next level of care down from medical stabilization and provide support for those that continue to require 24-hour supervision and medical monitoring but are found to be medically stable.

Those appropriate for RTC often continue to struggle with poor motivation, experience intrusive repetitive thoughts 4–6 hours a day, and are cooperative but often solely due to the highly structured aspects of this treatment level.

RTCs provide the support of a medical and therapeutic staff which often includes a psychiatrist, a dietitian, a therapist, and mental health workers.

These facilities have programming for approximately 14 hours every single day of the week with half a day of programming on Saturday and the day off on Sunday.

Individuals participate in various activities, individual, group, and family therapy, and 6 meals per day which include breakfast, lunch, and dinner as well as 3 snacks.

These facilities provide a wonderful opportunity for individuals to begin to practice autonomy and ownership of their recovery-focused behaviors in a contained environment.

Partial Hospitalization Program

Partial Hospitalization Programs (PHPs) increase an individual’s independence, as they live and sleep at home and attend treatment during the day. When an individual is in treatment for their eating disorder, treatment and recovery becomes their job until they reach the point that they can attend outpatient appointments only.

Those appropriate for PHP are often partially motivated but continue to struggle with intrusive and disordered thinking more than 3 hours per day.

These programs are often a minimum of 5 days per week and range from 6 to 11 hours per day.

Individuals in PHPs eat many of their meals while in treatment but are also challenged to complete some meals at home.

The stressors that occur when one begins to rejoin daily life, such as conversations and behaviors with family or roommates or triggering life events, can bring about relapse if one doesn’t learn how to slowly cope with it.

The limited variety of PHP allows them to recognize triggers and trouble areas that they can then process and work to improve in programming.

Intensive Outpatient

It is at this level of care that an individual may be able to return to areas of their previous life such as attending work or school.

Those in intensive outpatient (IOP) attend programming 2 to 3 hours per day for 3 days per week.

The number of meals engaged in during programming is reduced in this level of care, giving the individual increased opportunities to engage in daily life while maintaining recovery.

Outpatient

The lowest level of care is often reserved for those maintaining their eating disorder recovery.

Outpatient often consists of weekly meetings with their team, which includes their therapist, dietitian, physician, and possibly a psychiatrist.

It is encouraged that those engaging in outpatient treatment directly after going through various higher levels of treatment work with professionals that are trained in eating disorders.

On an outpatient basis, eating disorder trained professionals will still, at times, eat a snack or meal with their clients to engage firsthand with possible eating disorder behaviors and support their clients in maintaining appropriate relationships with food.

Your Role

When entering eating disorder treatment, you do not have to concern yourself in determining which level of care is appropriate for you.

Reach out to an eating disorder professional or therapist to assist you in reaching out to facilities and they will assess you to determine the appropriate level of care.

To learn of eating disorder professionals in your area or that you may have access to virtually, consider checking sites such as IADEP or EDDietitians.com.

Some individuals will require starting with medical stabilization and stepping down to each level of care as is appropriate.

For others, they may begin treatment early enough to begin at a lower level of care such as PHP or IOP.

Regardless of where one begins, the recommendation is often to step down level-by-level to titrate down level of care, supervision, and independence as this is shown to provide the most successful recovery outcomes long-term.

Altogether, do not be afraid to ask any questions that arise as you navigate this journey. You are not expected to know everything and it is okay to ask the necessary questions to inform yourself.

Resources

 [1] Goldberg, R. “The Eating Disorder Trap.” BookLogix, March 30, 2020.

[2] Gaudiani, J.. “Sick Enough: A Guide to Medical Complications of Eating Disorders.” Routledge, 2019.