How Long Will I Be in Treatment?
By David L. Tobin, PhD
Reprinted from Eating Disorders Recovery Today
Summer 2004 Volume 2, Number 4
©2004 Gürze Books
Most patients do not ask me how long they will be in treatment for an eating disorder, but this may be one of the most important ingredients in their recovery. The length of treatment varies greatly from patient to patient and, unfortunately, very little research has directly addressed this question.
One study suggests that to have the best chance of reaching and maintaining a healthy weight, patients with anorexia nervosa need to remain in a hospital-based program until they reach a normal weight. However, for some patients this may take a few weeks or months, and many require years of overall treatment including outpatient care.
What the research says
More clinical trials have been reported for bulimia nervosa, but none have specifically addressed the question of how long patients need to be in treatment. Most of the studies have been similar in length, including about 19 therapy visits and lasting approximately 6 months. However, not everyone in these studies recovers, which suggests that some patients need more therapy. Also, some patients appear to recover in just a few visits.
It has been shown that patients who recover very quickly, say within the first four visits, have the best chance of remaining in recovery after one year. Another study found that the percentage of patients who improved correlated positively with the length of treatment: the longer, the better.
Because so little research exists, it is hard to predict which bulimia patients will need more treatment and which will need less. A few studies suggest that patients with more complicated diagnoses such as multiple psychiatric disorders will have a more difficult recovery than patients who have bulimia nervosa alone. For example, patients with personality disorders or severe trauma-related conditions are likely to require more than just the cognitive behavior therapy offered in a standard research protocol for bulimia.
The one symptom that may predict such serious comorbid conditions is the number of unhealthy compensatory strategies. A patient who uses three or more strategies (vomiting, fasting, laxatives, diet pills, diuretics, lack of insulin, etc.) is more likely to have either a trauma-related condition or personality disorder. Treatments to address these very serious conditions include dialectical behavior therapy, expressive psychotherapy, and specific treatments for dissociation. All are much more intense and of greater duration than a standard cognitive behavioral protocol for bulimia nervosa. They often require several sessions per week for at least a year, and frequently for several years.
Even fewer studies have covered patients who binge eat and do not purge and patients who do not binge eat but do purge. Many people suffer from these conditions. However, additional personality and trauma disorders are also likely to complicate the treatment process.
For comparison purposes, it might be useful to look at research into the length of treatment needed for problems other than eating disorders, including depression, anxiety, and addictions. One group of studies found that about 20 percent of mixed outpatient clinic patients recovered in 2 visits, 50 percent recovered in 8 visits, and 60 percent recovered in 20 visits. Personality disorders required the longest time and the highest treatment dosage.
Another study that followed bulimia nervosa patients in an outpatient clinic found that those with personality disorders needed a very high dose of therapy—about 100 visits over the course of a year.
Stage of Readiness
A large body of research has addressed a person's stage of readiness for change in overcoming a wide variety of behavioral problems, and this research is finally being extended to cover eating disorders. These studies offer a simple way to determine how much treatment you might need. Just answer the following questions: Am I ready to change my problem behaviors in the next 30 days? In the next 6 months? Or am I unable to make a commitment to change at this time? People who say they can change in the next 30 days are the most likely to succeed and the most likely to benefit from smaller doses of treatment. People who feel they might change in the next six months will probably need more treatment, and people who are unable to commit to change will require the longest treatment.
One thing I tell patients is that no matter how much therapy you need, there is always hope of recovery if you stay in treatment. This is particularly important for patients who struggle with complicated and multiple disorders and may not do well in cognitive behavioral treatments that include only 20 visits or so. And while more research is needed to address the question of how best to help these patients, it is useful with these more complicated presentations to look for a clinician who has experience and a good track record of success in dealing with them.