Shades of Grey – Ethics in the Treatment of Eating Disorders
By Kendra Wilson, MSW, LCSW, CEDS-S, DBTC
The journey towards recovery can take many forms, but every person has to follow their own path towards health and make choices along the way. Some of these choices may come in the form of different treatment centers or levels of care to address the difficulties someone is having at that stage of their recovery. Every person’s process is different. There are several ethical decisions that need to be made in the course of care, by both the treatment team and the client, that may not be obvious at first.
“Levels of Care” in Eating Disorder Treatment – an Overview
Eating disorders are very complex illnesses that require specialists to treat not only the emotional and behavioral facets of an illness, but the medical one as well. For these reasons, the American Psychological Association (APA) established guidelines for appropriate levels of care with eating disorders. To see the full APA criteria for eating disorders, click here. This is the first level of ethical considerations when deciding what kind of care someone with an eating disorder needs.
Usually, these difficult conversations start when we, as clinicians, recommend a higher level of care for someone who we do not think is appropriate for outpatient or Intensive Outpatient Program (IOP) treatment (the services we provide at our center – Chyrsalis Center, NC). To be appropriate for outpatient or IOP, a person must be:
- Medically and psychologically stable to the point they are not a danger to themselves or others
- Motivated to recover
- Able to control their thoughts and behaviors using appropriate social support
When someone needs a higher level of care, they are usually:
- Medically compromised (by weight, bloodwork, EKG, etc.)
- Unable to manage their behavior
- Un- or under-motivated
- Not functioning in their lives in some significant way (work, family, relationships, etc.)
- Unable to manage a co-morbid condition (psychological or medical) because of their eating disorder
Levels of care indicate how much structure, support, and observation a client requires at that stage in their recovery.
When someone needs a higher level of care, it can be a very difficult discussion between provider and client. Sometimes, we all know it is coming and have been trying to avoid hospitalization but it just is not working. Other times, clients may take a sudden turn. This could be for many reasons, but the important thing is that clients get the help they need to recover from their eating disorder and co-occurring disorders. Our goal is always to help our clients and keep them focused on living healthy and productive lives, and we try to balance all their individual needs while keeping the goal of a full recovery foremost in our minds.
It is important to use the right tool to complete a task, and sometimes that tool needs to be a higher level of care in order for someone to truly recover. Often, hospital and residential levels of care can get clients back on track faster than outpatient could and sometimes that is necessary for someone’s well-being or even survival. PHP and IOP levels can provide support to keep someone out of the hospital or they can provide support as a step-down program. The transition between inpatient and home can be very stressful and there are a lot of facets to consider including social, family, academic, or work stressors. All of these are affected by or contribute to eating disorder behavior. A person cannot live in a vacuum, so all of these need to be managed before someone goes back to their regularly scheduled lives.
Multi-Disciplinary Treatment Teams
The standard of care in all levels of treatment includes a multi-disciplinary team with a therapist, dietitian, medical, and psychiatric doctor at a minimum. The team can also include various medical and mental health specialists (for example a GI doctor or a family therapist), and the client’s support system, to encompass all the concerns for the client.
In eating disorder care, not having a dietitian or a medical doctor on board and in regular communication with the therapist is unethical. It is the equivalent of having a missing member of a surgical team, like not having a nurse or an anesthetist. It is not safe for the client, no matter what the client may believe. There are times when the makeup of the treatment team may change – perhaps the client is not on psychiatric medications or they have been medically stable for a significant period of time and no longer go in to see a member of their medical team regularly – but it is not just who is on the team that is important. It is also that the team communicates effectively, which usually means the team has a leader. This is most often the primary individual therapist, as this is the person who usually sees the client the most. As a team leader, it is your job to coordinate the rest of the team, even when there is resistance. Your job is also, usually, to be the eating disorder expert on the team – if you are not an expert, you will need to get supervision from someone who is, even if they are in another discipline.
You cannot effectively treat a client with an eating disorder without the information these specialties provide, but the same is true when the team does not function. This requires leadership, regular communication, and an awareness of the pitfalls inherent in this population. “Splitting” or the dividing of the team by the client, family, or another team member that does not allow them to communicate effectively, is one cause of discord. An example of splitting would be when someone goes to one member of the team to ask for something but doesn’t like the answer, so they go to someone else to ask again. The key to managing splitting behavior is constant communication and clarity about the fact that team members communicate frequently.
Another aspect of a healthy treatment team is a cohesive treatment style and methodology amongst the team members. This is easiest if you work in a team and have regular team meetings, but can also be around using a similar style, language, or method – like Dialectical Behavior Therapy (DBT) – to communicate concepts to the client. Other tools, like treatment agreements or contracts, also need to be shared amongst all team members and clarified so everyone is giving the same message to the client.
Things can get very confusing if the therapist or psychiatrist give nutrition guidance, or the medical doctor contradicts the therapist. Though this unfortunately happens, we all need to be aware of our strengths and limitations on the team so we can make sure the client is talking to the best person to answer their questions and the client gets consistent information. The last thing any treatment provider wants to do is block a client getting the care they need, so we all need to “stay in our lanes.” Sometimes, we need to think about our motivations for helping, and also, to make sure the best interests of the client are the primary consideration.
Finally, resources are sometimes not available. This may mean you are working with team members who have little or no eating disorder treatment experience, or there are no providers, at all, in your area. Again, this is when supervision and consultation are the most useful and ethical things you can do. To get consultation or supervision for eating disorder treatment, the best option is the International Association of Eating Disorder Professionals (IAEDP), who have lists of supervisors and consultants around the world.
Other Barriers to Treatment
Aside from building and maintaining an effective team, there are a number of other barriers to treatment. One of the biggest is financial or insurance limitations on care. Despite parity laws, sometimes nutrition benefits for eating disorder treatment or even higher level of care are not covered by insurance or the client doesn’t have means to get the treatment they need. This is an unfortunate and heartbreaking reality for many providers. We are our clients’ best advocates (other than themselves, when they are able) and need to challenge insurance and financial barriers in our clients’ best interests. Sometimes, we will appeal denials or even write to the state Attorney General or the state Insurance Commission if the disparity is egregious.
In order to recover, every client needs a support system – recovery is not something you can reasonably do alone, and an eating disorder is very unlikely to go away on its own. Sometimes clients need to be convinced of this as well, but most of the time the families and other support people will do what they can, especially if they get psycho-education about eating disorders. The National Eating Disorder Association, or NEDA is a good resource for education information.
Many people tend to adhere to the stigma associated with mental health care in general and eating disorder stereotypes in particular. Our culture does not make that any easier with an artificial focus on dieting, appearance, and weight that has a long history and is supported through advertisements and social media. Though it is an uphill battle, empowering clients and their support systems to fight stereotypes and ignorance is hugely important. A number of eating disorder associations and advocacy groups have banded together to develop “The Nine Truths about Eating Disorders” that challenge some of the stigma and ideas about eating disorders that make recovery more difficult.
These are a some of the factors that influence care, but none more dominant right now than keeping everyone as safe as possible from the COVID-19 pandemic and still providing the care people need. If a higher level of care is needed, there can be no substitute for in-person treatment. However, many providers are able to provide tele-health now that restrictions have been suspended by many insurers. Providing telehealth can be another ethical consideration, especially in the treatment of eating disorders. Eating disorders are not just mental health disorders, but also medical illnesses. It is important we interact and assess our clients visually, as well as obtain vital signs information like weight and blood pressure, to adequately treat this population. Though in a situation like a pandemic, we might be able to reasonably suspend some of these requirements for a short period of time, in the normal course of events it is not ethical or reasonable to go without that information for long. Telehealth (therapy, nutrition, or medical) would be an appropriate adjunct, but not a substitute for face-to-face interventions.
Though there are other ethical and practical considerations in the treatment of eating disorders, these are some of the highlights we see every day in our practice. Every client, every treatment team is a little bit different. We hope to provide a bridge for clients on their journey in recovery. If you need us, we will be honored to work with you on that journey.
About the author:
Kendra Wilson, MSW, LCSW, CEDS-S, DBTC is the Clinical Director of Chrysalis Center’s IOP and their Compliance Officer and has over 20 years of psychiatric experience. Her specialized interests include eating disorders, mindfulness, depressive disorders, DBT, supervising, and compliant documentation & confidentiality standards. Kendra has certifications from IAEDP for their CEDS-S and Evergreen for DBT. She is presenting at the NASW-NC’s Clinical Institute in May, and presented on this same topic, with Kelly Broadwater, LPA, LPC, CEDS-S at Renfrew’s annual Symposium in 2019.