While no specific, therapeutic modality has emerged as a definitive, “evidence-based treatment” for adult anorexia* the body of research demonstrating what setting is most effective for treating adulthood anorexia is clear. Outpatient – not inpatient or residential – care as first-line treatment for anorexia in adults is now being embraced as protocol by international clinical bodies. The Royal Australian and New Zealand College of Psychiatrists’ (RANZCP) – whose guidelines, published in 2014, are most current – revised their latest set of protocols to state that adults with anorexia, including SE-AN individuals, should be treated in the least restrictive environment possible. Many individuals battling severe, chronic anorexia can in fact receive successful outcomes in outpatient care, the RANZCP handbook states. The guidelines are based on a review of all the most current research to date[iv].
Outpatient care is also recommended as first-line treatment for bulimia.
The growing consensus among researchers, globally, is that residential or inpatient treatment should be resorted to only when individuals are experiencing life-threatening medical complications, are at extremely low weights, or are unable to initiate change in any level of community-based, outpatient care. Even then, residential treatment should occur for as little time as possible, with patients stepped-down to lower levels of care as soon as they are stable, experts say.
That’s quite a contrast from the eleven months I was forced to stay – against my will – at the last residential treatment center I attended, in 2012. And I was stable less than two months following admission there.
The research supporting these updated guidelines include studies on SE-AN individuals that have emerged from pilot programs in Australia, New Zealand, British Columbia, Sweden and Canada over the past few years. The alternative, largely community-based models of care utilized in these areas will be discussed in greater detail later in this series. But they are showing that outpatient treatment such as a form of CBT modified for severe anorexia (CBT-SE), as well as Specialist Supportive Clinical Management (SSCM)**, is proving highly success for women like me. One outpatient, randomized controlled study comparing SSCM to CBT-SE had a program retention rate of 85 percent – almost unheard of for my population; both groups also demonstrated significant improvement on nearly all outcome measures, including at discharge and one-year follow-up.
The RANZCP clinical guidelines also state individuals with all manner of eating disorders should be provided Recovery-Model-oriented care – an approach which also stands in stark contrast to most, standard treatment in the U.S. today, where the medical model predominates. Recovery-oriented care, as the RANZCP handbook puts it, maximizes self-determination and choice in treatment, delivers it through community-based services and in partnership with consumer organizations, supports the development of new models of peer-run programs, and recognizes the dignity of individuals and their right to make their own treatment choices – even if those choices might not seem, at first glance, as the best choice by the person’s treatment team.
The American Psychiatric Association’s guidelines – written in 2006, and which therefore could not draw from the recent, SE-AN research – have no specific recommendation for treatment setting for adults or adolescents with anorexia. APA guidelines advise clinicians determine level of care based on parameters such as medical condition, patient motivation, and weight loss rate. However their 2012 “Guideline Watch” did note that leading British researchers recommend against long-term, inpatient care as first-line treatment for adolescents, based on a large, multi-site study which showed adolescents receiving inpatient treatment fared worse than those who received outpatient care[v].
“On the whole, these investigators concluded that under the British National Health Service there is little support for long-term inpatient care, either for clinical or for health economic reasons,” reads the APA guidelines. “Inpatient treatment [for adolescents] predicted poor outcomes.”
I find it interesting that none of the big players in the insular world of U.S. eating disorder treatment and advocacy – much less the residential programs themselves – are telling prospective clients or families about the lack of empirical support for what is still widely being touted as first-line care for adults battling severe anorexia.
For Tetyana Pekar, MSc – creator, writer and editor of the Canadian blog, “Science of Eating Disorders: Making Sense of the Latest Findings in Eating Disorder Research” – the problems inherent in the predominance of unregulated, for-profit residential treatment in the U.S. are impossible to separate from the politics and economics of our health care delivery system. In case you need a reminder – we live in the only Western, industrialized country lacking socialized medicine.
“This is one of the fundamental reasons why I think for-profit healthcare is ridiculous and unworkable… As an outsider I can’t even imagine any kind of regulation being passed. It is so crazy to me how people [in the U.S.] think for-profit corporations will self-regulate,” Pekar said, speaking to the lack of accountability or transparency the ED industry is held to. “[Because] what’s the point. They get tons of patients. They help some, surely. But I feel there’s just no motivation on their part [to, for example, track client outcomes]. It will only cost more money.”
Added Pekar: “That’s not to say that all these centers want to do is make money, or that they don’t want to help….But wanting to help is not enough, particularly if you are not utilizing evidence-based practices.”
*Proven, evidence-based treatments exist only for bulimia and adolescent anorexia. Those include cognitive-behavioral therapy (CBT) for bulimia in adults, and family-based treatment for adolescents with three or fewer years battling anorexia. Interpersonal therapy (IPT) has also shown some effectiveness with bulimia.
**SSCM combines features of clinical management and supportive psychotherapy, including techniques such as collaborative goal-setting, fostering a strong therapeutic relationship, and providing care, support, education, reassurance and advice. The therapy is flexible and individualized, and focuses simultaneously on gradual resumption of normal eating and improving quality of life. Progress toward life goals motivates individuals to further reduce core, eating disorder pathology and later, maintain these improvements.