The Transition Phase of Treatment: A New Model – Part 1. Beginning at the Beginning
By Mary K. Stein, Managing Editor
Reprinted from Eating Disorders Review
March/April 2007 Volume 18, Number 2
©2007 Gürze Books
Transition: A passage or movement from one form, state, or condition,
to another—Webster's New World Dictionary.
Traditionally the transition phase of treatment begins when inpatient treatment is nearly complete and the patient is preparing to go back home. At the Eating Disorder Center of Denver (EDC-D), however, transition begins when the patient first walks in the door, according to Center Director Kenneth Weiner, MD, and Clinical Director Tamara Pryor, PhD.
The EDC-D treatment program has a unique design using partial hospitalization, which differs from typical inpatient programs. Like other inpatient programs, the Denver Center offers an 11-hour treatment day 7 days a week. The program includes group and individual therapy, psychiatric and medical monitoring and three meals and two snacks facilitated by a dietitian and a master's level clinician.
This is where the similarities end: at the end of the treatment day, EDC-D patients return home or to an apartment at the Center or to local hotels. They can then apply what they have learned that day and practice healthy ways of coping in real life. EDC-D is one of only a few programs in the country that offers partial hospitalization for eating disorders patients.
Transition Begins at the Beginning
According to Dr. Weiner, the transition phase of treatment actually begins when a patient enters the program. Work on transition begins with a phone call within the first 48 hours to the referring therapist and to the referring psychiatrist. This contact continues once a week throughout the course of treatment. The Denver program also offers contact with the outpatient therapist on a weekly basis throughout the course of treatment. Patients also are involved with their care from the beginning and help define their own treatment goals.
Dr. Weiner says, "Any good intensive treatment has a beginning, middle, and end, but if you start thinking about transition at the end, that's too late and you are not going to be able to effectively accomplish your goals. The idea and goal of working to return to their lives is incorporated all through their treatment."
When a patient is involved in the program and their therapist is in the area, the therapist is invited to participate in the patient's staffing every week. Most therapists seem to like the idea of staying involved with their patients while the patient is in the partial program, says Dr. Weiner.
Inpatient vs. Outpatient Care: A Surprising Finding
Before joining the staff at EDC-D two years ago, Dr. Pryor ran an eating disorder program in Wichita, KN. A study by her group gave her a new perspective on inpatient care. She says, "We realized we were operating with the assumption that more is better and therefore inpatient care was a more effective form of treatment. We decided to do a study to find out if inpatients did better than outpatients. We were very surprised to find that outpatients did better than outpatients at 6 months and again at a 2-year follow-up."
The outpatients reported better outcomes because they had a greater sense of ownership of their recovery. She added that many of the patients who were inpatients felt that although they were able to interrupt their hurtful behaviors and did well in the hospital, but when they left the hospital they claimed, ‘it was like falling off a cliff.' They did not have the life skills to incorporate the changes into their lives once they left the program. Dr. Pryor also noted that compared to inpatients, outpatients had a better sense of self and more confidence to continue in their recovery. Joining the Denver program provided evidence of how an empowerment model that emphasizes increasing self-directedness through transition work can truly effect change.
Patients in the partial hospitalization program work all day in treatment programs, then go home to their apartments or homes in the evening and continue to practice their skills in the outside world. And, Dr. Pryor noted, if they have a problem or challenge with behaviors, they can come back the next day to discuss it, and to see what they might have done differently. She added, "We are working on transition every day they are here." This is also a population that has a great difficulty with change, she noted, adding that the treatment team coaxes them along with that outcome in mind, and are constantly working on helping patients take responsibility for their recovery, using lots of education and an expectation of success. Dr. Weiner adds, "Whether we are talking about inpatient, residential, or partial hospitalization, all these issues pertain to transition."
Patients must be 16 years of age or older and younger patients are seen at the nearby Children's Hospital of Denver. Most patients are admitted within one to three days after assessment, and the length of treatment is determined individually with each patient according to their diagnosis and needs. For patients with AN, the weight restoration goal is at least 90% of their ideal body weight. The length of stay in the partial hospitalization program ranges from four to eight weeks, and is individualized.
Does the Program Work for Everyone?
Dr. Weiner notes that during the five and one-half years the partial hospitalization program has been in place, only about 5 of 500 patients have needed referral to a higher level of care. "We try not to treat patients where there isn't a good fit, he added, and noted that people often underestimate the severity of the illness that can be treated with the partial hospitalization model of care.
He also added that part of what the treatment team attempts to do is to provide lots of education about the expectations of the program before a patient is admitted to the program. Nutrition is admittedly one of the largest hurdles. In the very beginning days of the partial hospitalization program, there was some difficulty feeding anorexics, partly because they would resist refeeding. Now, at the end of the first 48 hours of partial hospitalization, patients have to prepare their own food plan, or they must go on an alternate food plan. Educating the patients before they enter the program has made the difference. Usually it takes a few days for the patient to settle in to the routine of the program. Then being there becomes the leverage to do what they set out to do in the first place—getting well.
Patients like to be in the program, in a nurturing environment. He adds, "Our message is that you can't be here and do what you have always done, because then you will get what you have always gotten—if you do what you have always done, you're not going to get well." Patients are told that the staff would not be ethical if they allowed the patient to stay yet also to continue to engage in harmful behaviors. He has been amazed at how few people leave treatment once they have entered the program. By the time patients have gone through the education program, an orientation to the treatment model, and finally being admitted to the partial hospitalization program, once they get through the anxiety of the first few days, they don't leave treatment, he says.
Preparing to Leave the Program
Even with all the preplanning and structure, it is never easy for a patient to move from treatment to home, said Dr. Weiner. This is true even though patients go home each night, and even though they are continually working on transitioning back to their lives from the moment they enter the program. It is more difficult for patients from out of the greater Denver area, who cannot stay connected to the program via the Center's outpatient program. The EDC-D outpatient program allows a full continuum of care as long as needed. To help patients from outside the Denver area with transition, the staff is in touch with their referring clinician, and parents are encouraged to visit the program and to participate in person.
(Click here to read Part 2, the phases of transition and the role of the transition therapist).