Do I Need a Higher Level of Care for My Eating Disorder?
One of the most difficult questions in eating disorder treatment can be:
Is outpatient therapy enough for me right now?
Sometimes the answer is yes.
Sometimes someone needs more support than weekly outpatient appointments can reasonably provide.
And sometimes the answer changes over time.
Eating disorder treatment exists across different levels of care because people's medical, nutritional, psychiatric, and behavioral needs vary considerably. Needing more support doesn't mean you've failed at outpatient treatment—or that you have to wait until you're in crisis before considering other options.
What Are the Different Levels of Eating Disorder Treatment?
Eating disorder treatment generally ranges from traditional outpatient care to increasingly structured levels of support.
Outpatient treatment typically allows someone to continue living at home and participating in much of their regular life while meeting with members of their treatment team, which may include a therapist, registered dietitian, medical provider, psychiatrist, or other professionals.
Intensive outpatient programs (IOP) generally provide several hours of treatment on multiple days each week. This can offer additional therapeutic and meal support while allowing someone to maintain more of their usual daily routine.
Partial hospitalization programs (PHP) provide substantially more structure throughout the day, often including therapeutic programming, supported meals, nutritional care, and medical or psychiatric oversight.
Residential treatment provides 24-hour support in a specialized treatment environment.
Inpatient hospitalization provides intensive medical and psychiatric monitoring and may be necessary when someone requires acute stabilization.
The appropriate level of care isn't determined by diagnosis alone.
How Do We Know When Outpatient Treatment Isn't Enough?
There isn't one number, symptom, weight, or behavior that answers this question for everyone.
Level-of-care decisions should consider the whole clinical picture.
That may include:
Medical stability
Nutritional status
Frequency and severity of eating disorder behaviors
Psychiatric safety
Ability to interrupt behaviors outside of treatment
Ability to nourish yourself adequately
Available support at home
Co-occurring psychiatric or medical conditions
How much the eating disorder is interfering with everyday life
Whether meaningful progress is possible at the current level of care
Someone may technically be participating in outpatient treatment while spending most of the week unable to implement what is being discussed in sessions.
In those situations, the issue may not be a lack of effort.
There simply may not be enough support.
You Don't Have to “Look Sick” to Need More Help
One of the most harmful eating disorder myths is that someone's appearance tells us how sick they are.
It doesn't.
People across the weight spectrum can experience serious eating disorders and medical complications.
Similarly, someone doesn't have to reach a particular weight—or appear visibly ill—before a higher level of support can be appropriate.
Level-of-care decisions should be based on an individualized assessment of medical, psychiatric, nutritional, and behavioral needs rather than appearance alone.
Functioning Doesn't Always Mean You're Okay
People with eating disorders can sometimes continue functioning remarkably well while struggling significantly.
You may still be working.
Going to school.
Taking care of your family.
Meeting deadlines.
Showing up for appointments.
From the outside, things may look relatively normal.
Meanwhile, enormous amounts of mental energy may be going toward food, exercise, weight, body image, rituals, planning, compensating, or recovering from eating disorder behaviors.
Being able to function in some areas of your life doesn't automatically mean outpatient treatment is sufficient.
The more useful question is how much effort it takes to maintain that functioning—and what is happening underneath it.
A Higher Level of Care Isn't a Punishment
People are sometimes reluctant to consider more intensive treatment because it feels like evidence that they weren't trying hard enough.
It isn't.
Imagine trying to recover from a significant physical injury while receiving one hour of rehabilitation each week.
If you eventually needed more intensive rehabilitation, we wouldn't necessarily conclude that you had failed.
We might recognize that your needs exceeded what one hour of treatment could provide.
Eating disorder treatment can work similarly.
Sometimes a person needs more meal support, therapeutic contact, structure, medical monitoring, or containment than traditional outpatient care can reasonably offer.
That's information about the level of support needed, not someone's motivation or worthiness of treatment.
What If I Don't Want a Higher Level of Care?
This is where treatment decisions can become particularly complicated.
A clinician may believe that someone would benefit from more intensive treatment while that person feels unwilling—or unable—to pursue it.
There may be significant practical barriers.
Treatment can interfere with work, school, caregiving responsibilities, finances, relationships, or other commitments.
Insurance coverage and access may create additional limitations.
Someone may also have had previous treatment experiences that were frightening, invalidating, or simply ineffective.
And sometimes a person just isn't ready.
Those concerns deserve to be taken seriously.
At the same time, medical and psychiatric risks need to be taken seriously too.
This can require difficult but important conversations about what is recommended, what risks are present, what the individual is willing to consider, whether alternatives exist, and what can reasonably and ethically be managed in outpatient care.
What If I've Already Been to Residential, PHP, or IOP?
Having previously received a higher level of care doesn't automatically mean you need to return to one every time symptoms increase.
It also doesn't mean you should never return.
The question is what you need now.
Sometimes outpatient treatment after a higher level of care focuses on maintaining progress, navigating real-life challenges, addressing underlying concerns, and building greater independence.
At other times, symptoms may increase to a point where additional structure becomes necessary again.
Returning to a higher level of care doesn't erase the work you've already done.
Recovery isn't a pass-or-fail process.
You Don't Have to Wait Until Things Become an Emergency
People with eating disorders frequently minimize their own needs.
You may think:
Someone else is sicker.
I'm still functioning.
My labs weren't that bad.
I'm not thin enough.
I'm not doing the behavior every day.
I should be able to handle this myself.
But treatment isn't an award given to whoever becomes the sickest.
And needing more support doesn't require reaching the worst possible point first.
Earlier intervention can sometimes prevent further deterioration and provide support before someone's world becomes even more restricted by the eating disorder.
How Is the Right Level of Care Determined?
Level-of-care decisions are best made through individualized assessment.
A therapist may be one part of that process, but eating disorders can affect multiple areas of health. Medical and nutritional evaluation may therefore also be essential.
Depending on the situation, consultation with a physician, registered dietitian, psychiatrist, or specialized eating disorder program may be appropriate.
An evaluation also doesn't automatically commit you to entering a particular program.
It provides information.
Sometimes the recommendation will be to continue outpatient treatment.
Sometimes it will involve adding additional members to the treatment team or increasing support.
And sometimes a more intensive level of treatment may provide something outpatient therapy simply cannot.
The goal isn't to place everyone into the highest possible level of care.
It's to identify the amount and type of support that appropriately matches someone's current needs and safety.
Specialized Eating Disorder Treatment in Westport, Connecticut
Shoreline Eating Disorder Center provides specialized outpatient eating disorder treatment for adolescents and adults in Westport, Connecticut.
Dr. Joy Zelikovsky works collaboratively with clients and, when appropriate, medical providers, registered dietitians, psychiatrists, families, and higher levels of care. Treatment decisions consider the individual's needs, goals, autonomy, medical and psychiatric safety, and whether outpatient treatment remains appropriate.
In-person treatment is available in Westport, with telehealth available for appropriate clients throughout Connecticut.
A complimentary 15-minute consultation is available to discuss your treatment needs and whether outpatient care at Shoreline may be a good fit.
This article provides general educational information and cannot determine the appropriate level of care for an individual. Eating disorders can cause serious and potentially life-threatening medical complications. If you are experiencing an immediate medical or psychiatric emergency, seek emergency care.
