I want to start with this: Inpatient treatment for eating disorders save lives.
I often tell adults suffering from eating disorders who are underweight and struggling to re-feed themselves to seek inpatient treatment. It is the kick start to weight restoration that many people need. That said, the real work starts when a person comes out of inpatient.
I’ll also note I tossed and turned a couple of nights wondering if I should publish this blog or not. My dilemma being that I would hate to put anyone off going to inpatient treatment. I’m going to be careful and hope not to do that. I’m not going to try and wrap people up in cotton wool either because I think that is more damaging than protective in the long run.
When faced with inpatient, adult patients and their families should be aware that is a needed step but that it is not a complete treatment and it has limitations. Also be aware that some centres are better than others so use the community of professionals who base their practices on evidence-based treatments to help you find a good one.
This post is long. Please read all of it before you jump to a conclusion about what the message is. Thanks.
P.S. Every time I write inpatient, my fingers autocorrect it to impatient. For some reason that really tickles me. Here’s hoping by the time I publish this I got all the impatients out.
I never went into inpatient treatment because I was too stubborn and too sick to know that would have been a great idea. And I still, still — regardless of some of the stories that I hear from some sufferers about inpatient stays —, I still believe that when I was underweight inpatient treatment would have been the kick start that my recovery process so desperately needed.
I’ll say that again. One of my biggest regrets is not checking myself into inpatient treatment and handing the problem of getting some much needed weight on my starving body over to someone else. While we are on the subject of things that I should have done, I should have also had my parents lined up so that after my inpatient stay I could move back in with them and allow them to re-feed me and continue my treatment.
Because no matter which way you look at it, inpatient treatment for eating disorders is a kick start for weight restoration.
The reason that I get angry when I hear stories about idiotic behaviour by inpatient treatment providers is because a good inpatient treatment solution is so desperately needed.
We need it! We need it to work! When it works, it is the fastest and safest way to get a person with an eating disorder out of the immediate danger zone. I am a fan of inpatient treatment. I recommend it to people on a very regular basis. We need it. But for the love of God we need inpatient treatment centres so stop doing bloody stupid shit that sometimes really messes people up!
Just this week, someone wrote this to me, she is in the UK:
Tabs there are so many potentially very damaging rules IP units have…. You are not allowed to eat under your meal plan but also you are not allowed to go even a spoonful over your plan!!
You did hear some ridiculous things that staff would say were ED behaviours in those places – another reason that avoiding going back is high on my priority list!
I am a pure restricter in my ED – never binged in my ED at all and always had strict restrictive tendencies so for me if I were to ‘allow’ myself something extra to my plan would be a huge step (and as we know in recovery there is no too much!). However, I remember being really upset one morning when we had to measure our milk out for our cereal in a jug so it is 200ml – now you would think this is to make sure we don’t undercut which people would try to but on this occasion there must have been about 10ml over in my jug and so when the nurse checked it she told me to pour a bit back into the carton!!! I could not believe it as a, was not going to harm me in anyway if was 10ml over and if it was then it would be good for my recovery to do it and loosen the control a bit – still madness reigns in the staff more than the patients sometimes!
Here you have someone with a restrictive eating disorder being told to pour back 10ml of milk. You cannot make this shit up. I get that “binge eating behaviour” cannot be allowed in treatment centres. But 10ml of milk? Really? Where is the common sense here?
Do providers realize that this person came out of that treatment centre “weight restored” but very confused and lost. Is it any wonder that she lost weight as soon as she came out?
This one is from two weeks ago:
I have just listened to your latest podcast on exercise in anorexia and felt the need to contact you right this minute!
I myself have suffered from anorexia for 10 going on 11 years now. Although I am trying my out right best to recover now, I like you did am struggling with the exercise side of things. My eating is much better as at least now I do allow myself to eat but the exercise side of things is trickier.
This sounds crazy but my exercise issue actually got worse when I left an inpatient unit to try and help me get better. Yes they helped in the sense of gaining weight but in the unit we were to have 2×20 minute walks per day and ever since leaving the unit (6 years ago now!!) I have felt that I still have to do this everyday as that is what they told me to do in there and surely they were professionals right?!!!??? It’s sooooo frustrating and difficult to think of a reason why not to go for the walks as like I say, it was them that stated this and my head is telling m it must be a healthy amount to do as they were professionals and any less is unhealthy to do.
It’s a tricky situation I am stuck in and I have no idea how to get out of it.
I don’t want to do the walks everyday and they do get in the way of my day to day life at times but I can’t help but feel like I should do them due to the fact they have us them in a hospital environment.
Who can I sue for the brain cells that I have lost every time I slam my head against my desk when I receive emails like that?
SIX YEARS LATER and this woman is still struggling to get rid of the exercise regime that her eating disorder picked up in a treatment centre. Eating disorders love to tell us that the behaviours that it makes us do — such as compulsive exercise and strict rules around food — are “healthy” and “right” so when they are backed up by “professionals” the person suffering from the eating disorder doesn’t stand a chance when trying to reason out of it.
Now, I know from brilliant people such as Dr Laura Hill that some “movement” after a stressful meal can be helpful, but labelling this as “exercise” or “walks” is where the problem lies I think. Also “movement” should be optional, not vigorous, and more like a short enjoyable ten minute stroll.
I think that second email shows classically how the sufferer’s “healthy” brain knows that compulsive walking is not good for her, but the “eating disorder brain” won’t let her get out of it. In a follow up email she admitted to me that she feels the only way she can get this bad advice out of her head would be to go back to the inpatient centre staff that told her it and have them tell her she can stop doing the walks. Like she needs some sort of closure, or their permission because they are the “professionals.”
Notice how in neither of these examples the patient has learned ED-behaviours from other patients. Nope. Both times they have learned them from the professionals running the joints.
I was feeling that this is a little too biased, so I asked my Slack group for positive things about IP stays. Here is one:
I think in the UK we are incredibly lucky to get IP free on NHS when we need it and if medically unstable they are life savers at times….
They do work hard to get people eating regularly again and right amounts (even if they are pedantic about the going over meal plan side)…
I have also seen people with purging tendencies managed well IP.
Some people i have also seen completely turned around in IP treatment – they are admitted literally fading away in every sense – not just physically and weight wise but their eyes are dull, they are monosyllabic and just putting a morsel of food or milk to their mouth is absolutely terrifying for them. However, with the right IP support, encouragement and regular nutrition they start to flourish and they leave treatment healthy weight, sparks to their eyes, laughing and joking, motivated to live again and excited about eating! That is great to see and without the IP push who knows where they might have ended up?
YAY FOR IP!
I mean that from the bottom of my heart. I love to hear about lives being saved and especially in those cases where a person has all but given up.
The NHS in particular where IP is free for those who are medially unstable. That rocks!
We need to work with treatment centres
For helping someone put on enough weight to get out of immediate danger — IP can be a fabulous aid to kick starting recovery. But because the brain doesn’t heal from an eating disorder at the same rate the body does, it is critical that common sense is used and patients are not long-term damaged in the time that they spend there. I’m talking about coming out with more ED behaviours than they went in with.
Nobody is going to be “healed” by a month in inpatient. But if we can make that very clear from the get-go, plans can be put in place for when the person comes out.
Plans such as:
- Involving the family and training them in Family-Based Treatment.
- Having an outpatient treatment team lined up.
- Having meal support ready so that the patient doesn’t go from 24/7 meal support to nothing in the space of a day.
IP can start the recovery process. IP saves lives. But the message has to be loud and clear that IP is a starting point, not an end point.
All that has to happen after inpatient. And re-feeding in the home has to continue after inpatient. This is a time for CBT and whatever other sort of therapy works for the patient as they are more weight restored and therefore hopefully able to think a bit better.
I think inpatient treatment for eating disorders at the moment is a bit like any hospital operation stay — you’ll come out better than you went in physically, but possibly with some new scars. In the case of a person with an eating disorder, these scars will be mental, and they can take a very long time to heal. The frustrating part is that the are avoidable.
Let’s work together to perfect this system. Let’s make it so that people come out of IP with fully support in place — and I am talking about adults, not just the kids. Let’s make it so that nobody needs more than one trip to IP because they are supported all the way to full recovery when they come out.
We have all the tools and the knowledge to make this a reality. But we have to start here — in the uncomfortable space of talking about the problems in the process as it is — in order to affect a change.
I have had two IP experiences, one pretty bad and then a second that was life saving and truly set me up for success upon discharge. I have not had to return to that high of level of care since discharging and I truly believe it’s in a large part because of the high quality of care I got and the very strong discharge plan they helped me and my family implement.
What was key to this center was that family was involved from day 1 even as an “independent” adult. Family therapy was looked at as a chance to problem solve and improve communication versus a blame game or a time to rehash old issues again and again. The center strongly believed that your first line of support was your family and therefore involving them in your care from day one was crucial.
Discharge planning also started on day 1 at this center. There was a constant focus on “…and how will this translate outside of here” or “how can the support you’re receiving right now be replicated in the outside world.”
The unit was strictly run but there was room for flexibility. The center overall was small so each individual’s case was looked at seperately meaning there were no general rules such as not being allowed to overfill ones cup by 10ML. Flexibility was encouraged even when it caused upset.
My discharge plan was set up by me with input from my family and therapist. It was extremely specific from everything down to weight ranges to what time of day I would perform specific tasks. Meal support was in place. No two clients discharge plans were alike. There was no form everyone used. It was personalized by each client with their therapist.
What made this stay successful I think can be summed up best in three components: family involvement and the approach their took to family, individualized treatment and strong discharge planning.
Kate, this is huge.
Family is key. This disorder is such that it is unrealistic to expect sufferers to be able to continue eating without the help and active encouragement of the family. I am so pleased that your second IP experience was this!