The Partial Hospital and Intensive Outpatient Option

Dr. PertschukArticle Contributed by: Michael Pertschuk, M.D. – Medical Director, Eating Disorders Treatment Center (EDTC) & Brandywine Hospital

Eating disorders present a strikingly diverse group of problems.  Symptoms of Anorexia, Bulimia and Binge Eating Disorder can range in severity from relatively mild to life-threatening.  They can be associated with an array of physical and psychological complications. People may use symptoms occasionally under stress or habitually to the point of crowding out all other normal activity. In response to this diversity, a corresponding range of treatments and treatment settings have developed to meet the varying needs of individuals with eating disorders.

Matching treatment setting to client need is one of the major tasks of eating disorder treatment professionals.  Typically, clients with medical issues start their treatment at a hospital level.  Severe malnutrition from anorexia, repeated emergency room visits for dehydration and blood chemical imbalances caused by purging with bulimia, and uncontrolled diabetes and hypertension or heart failure from morbid obesity secondary to binge eating may all lead to the need for highly structured, medically supervised, psychiatrically intensive treatment that can only be provided in a hospital setting.  On the other hand, symptom use that is occasional and has not yet had a major impact on educational, vocational or social functioning usually can be treated with weekly outpatient counseling, sometimes in combination with nutritional consultation or family therapy.

Then there are the “in betweens,” situations where symptom use is not severe enough to require round the clock medical supervision in a hospital, yet too severe to be treated in weekly outpatient counseling. This is where day treatment programs come in to play, typically referred to as Partial Hospital or Intensive Outpatient Programs.  These are outpatient programs structured to provide a range of coordinated services in one place.  Generally, Partial Hospital Programs (PHP’s) offer more services than Intensive Outpatient Programs (IOP’s).  They also tend to involve longer hours and more frequent visits. Partial Hospital Programs typically include individual, family, and group counseling, medication management, nutritional counseling and meal supervision. Care is provided by a treatment team that includes dietitians, psychiatrists and counselors. Partial Hospital Programs typically operate three to five days a week, and hours can range anywhere from five to 12 hours per day. Frequency of visits and number of hours usually depends on the individual’s needs, and programs will often taper both the number of hours and days per week of attendance as an individual progresses.

While most Partial Hospital programs operate during the day–requiring participants to take a leave of absence from school or work–some programs operate in the late afternoon/evening hours to accommodate clients who wish to receive intensive treatment with the least amount of interruption in their daily lives. These programs emphasize the importance of the individual’s functioning in as many normal activities as possible while receiving care.

Intensive Outpatient Programs are less intensive than Partial Hospital Programs, offering a more limited range of services. They usually operate two to three days a week for two to three hours a day. IOP’s are often used as a step-down from Partial Hospital level of care as they allow for a longer period of treatment in a program setting with a gradual taper back to once weekly outpatient counseling.

PHP’s and IOP’s often work best when the client acknowledges that he or she has a problem and when there is an identified support network in place, such as family and close friends. Just as there is a treatment team providing care, there is a “team” involving the professionals, the individual and his or her social supports. Successful treatment is truly a joint effort. There is also one huge advantage for patients receiving treatment in Partial Hospital and Intensive Outpatient programs: gains made in this setting are more likely to endure since they are accomplished while the individual is in his or her normal environment, engaging in normal activities like school, homemaking or employment.

Clinical Example:  Jill is a 15 year old high school sophomore with an 18 month history of weight loss through dietary restriction and exercise.  She lives with her parents and an older sister.  On evaluation she is 64” tall and 87 lb.  Her Body Mass Index (BMI) is 14.9.  Her pediatrician ordered labs, which showed some signs of malnutrition such as mild anemia, but nothing to indicate acute danger.  When the possibility of inpatient hospital care is raised with Jill and her family, Jill insists she will comply with treatment in a Partial Hospital program so she can receive the intensive therapy she needs but remain at home and attend school as usual. Jill enrolls in a Partial Hospital program, attending treatment several days a week after school.

Jill’s parents agree to supervise meals at home, but need guidance from the program dietician on appropriate nutritional expectations. The client and her parents meet weekly with the program dietician.  Initially, there are “battles” over meals at home, although Jill complies with meals in the program. We revisit the possibility of inpatient hospital care if Jill is unable to manage meals at home with her family’s support. With ongoing family therapy in the program, Jill finally “gets it” that her parents are not going to ignore the problem or give up and accept her low weight as a compromise.  Eventually, meals at home become easier, and Jill benefits from a range of therapies in the program, learning from her peers in groups and exploring the underlying issues of her eating disorder with her individual therapist. She learns better ways of managing conflicts with her sister and negotiating for appropriate areas of independence with her parents.  The treatment team also works with Jill on areas of strength–such has her singing ability–to improve self-esteem.  With progress, program attendance is reduced from three to two days per week, and Jill and her parents prepare for the transition from the program back to weekly outpatient counseling. With consistent follow-through in outpatient counseling and the continued support of her family, Jill’s prognosis is very good.

This is a client who legitimately could have been referred for inpatient hospital treatment, but Jill’s age, lack of immediate medical issues, and demonstrated parental willingness to do “whatever it takes” made it possible to provide her care in a Partial Hospital setting.  Because she made essential changes while at home, assisted by her parents, we are optimistic that these changes will persist as she transitions to weekly outpatient counseling.

As someone who has directed specialized treatments for eating disorders in hospital, residential, partial hospital and intensive outpatient settings, I find an especial affinity for these latter two approaches.  As I have observed over the years, partial hospital and intensive outpatient programs, when offering a sufficient range of services, can help clients accomplish major changes.  They do so while avoiding the “life in a bubble” effect, which can happen in extended inpatient or residential settings.  At the same time, it is important to recognize the limits of these approaches.  They cannot substitute for hospital care when there is acute medical instability or when symptom use is so ingrained that families, even with close support, cannot interrupt symptom use.  Nor are they a “final step” in the treatment process.  When symptoms are severe enough to require partial hospital or intensive outpatient programs, the individual will need ongoing outpatient follow-up after leaving a program to build on changes accomplished and prevent relapse.

 

Page Last Updated and Reviewed By: Jacquelyn Ekern, MS, LPC on September 11, 2013

Published on EatingDisorderHope.com, Eating Disorder Resources