Stepping Up for Eating Disorder Recovery: 7 Ways to Help Your Client Progress

Eating disorders are extremely complex. They are also treatable . As your clients move through treatment and recovery, sometimes outpatient support is exactly what they need, while other times something more intensive will help them reach their goals.

When you notice your client isn’t progressing in the outpatient setting, it might be time to consider a higher level of care (HLOC).

Tip 1: Know the signs that your client needs a higher level of care

As outpatient providers, it can be hard to know when our clients need a level of support that outpatient services cannot provide. Despite the client's commitment to getting better, the outpatient setting may not provide enough support for clients to access recovery.

Ask yourself, is your client:

• Engaging in eating disorder behaviors daily or almost daily?
• Experiencing adverse social, educational and/or vocational setting impacts due to the eating disorder and/or co-occurring conditions (like anxiety, obsessive-compulsive disorder, depression, trauma)? 
• Struggling with motivation levels or ambivalence that would benefit from a more structured environment? 
• Experiencing limited social support that contributes to worsening symptoms? 
• Needing or wanting increased support from family and friends? 
• Needing daily, or almost daily, external intervention and support for nutrition rehabilitation? 
• Experiencing medical complications (like bradycardia and/orthostasis, abnormal labs, fatigue, cold intolerance, dizziness and/or hair thinning/loss)? 
• Exhibiting significant changes in weight (increase or decrease) with no known medical cause? (Important note: Eating disorders impact diverse individuals in diverse body shapes/sizes.)  
• At or below 85% of their ideal body weight for age? (Important note: Body weight is not a sole determinant of eating disorder diagnosis or overall health.)

Note that this list should not be used as an assessment tool. A comprehensive no-cost assessment should be completed if you are concerned about your client’s progress and you are considering recommending a higher level of care.  should be completed if you are concerned about your client’s progress and you are considering recommending a higher level of care.

Schedule a care consultation today.

Tip 2: Be prepared to navigate tough conversations

Once it becomes clear that your client likely needs an HLOC, you may feel a little nervous about broaching this topic with them. Ellie Pike, MA, LPC, senior manager of alumni, family and community outreach at Eating Recovery Center (ERC), shares her perspective on having this initial conversation:

“Looking back to the first time I recommended a step-up in care for a client, I remember feeling so nervous! I was worried that the client would get angry and leave care -- meaning they might not receive any care,” explains Pike. “I was worried that it was a sign of failure -- maybe I wasn’t doing a good enough job as their therapist. As the clinician, I needed to be reminded that there is hope for recovery through lived experience stories and sometimes I needed to let go of my expectations for myself and my clients.”

Pike continues, “Moving past my ego -- my hopes that outpatient therapy was ‘enough’ -- was only part of the journey. I also needed to learn how to effectively relay to my clients that there is more to recovery, and it is worth their sacrifices, hard work and commitment to treatment.”

Tip 3: Meet your clients where they are

Relaying hope for recovery, and the why behind a step-up in care, can be challenging. During these conversations, it is important to meet your clients where they are -- partnering with them rather than pushing them. This approach can:

1. Help both you and your clients create more realistic expectations
2. Help your clients create greater success over time
3. Help prevent you from experiencing frustration and burnout

If a client expresses mixed feelings or hesitancy about stepping up to a higher level of care, that is completely normal. Motivational interviewing (MI) is an effective technique that can help you partner with your client to create change.

Tip 4: Use motivational interviewing

Motivational interviewing is a client-centered, empowering approach to helping your clients determine their personal goals or “reasons” for change. MI encourages warmth, genuine connection, respect and support of the patient’s self-determination and autonomy. Watch an on-demand motivational interviewing training here.

As you are addressing ambivalence with a client, consider these approaches:

• Validate your client’s feelings. “Understand that the version of themselves that is in crisis feels incredibly vulnerable and has a lot of self-doubt and fear,” says Elizabeth Easton, PsyD, CEDS, director of psychotherapy at ERC. Acknowledge and validate these understandable feelings so that your client can feel truly heard and understood. This is the first step toward further unpacking their feelings and thoughts about possibly stepping up to an HLOC.
• Explore their perspective. Ask your client to explain their reasons for ambivalence, and listen with curiosity, warmth and respect. You can explore further by asking your client what they stand to lose by entering an HLOC, and then asking them what they stand to gain. “Walk with your client, not ahead of them,” says Maggie Moore, MA, LMFT, national family outreach manager at ERC.
• Involve their support network (if/when possible). Support persons (parents, spouses, chosen family, etc.) may also have worries or concerns about their loved one stepping up a level of care. By taking the time to meet with them (separately, or with your client – depending on circumstances) you create space to hear and address family system-wide concerns. Educate support persons about opportunities to continue being involved in the treatment process as they may have concerns about being “cut off” or “shut out” during HLOCs.

Tip 5: Set boundaries

For mental health care providers, boundaries are especially important when supporting a client through eating disorder recovery. Michelle Cross, LCSW, RD, CEDS-S, senior primary therapist at ERC, has a few boundaries she typically puts in place after identifying the need for an HLOC. Cross says she typically considers:

• Focusing on skills: “Sessions can be spent talking about the fear of moving to an HLOC,” shares Cross. “Focus on what skills they are currently using to stop the maladaptive behaviors, and remind them that they are trying the best they can. It's just that this illness is too hard for anyone to conquer on their own.”
• Involving friends and family: When ethically and clinically appropriate, Cross holds time for involvement of the client’s loved ones (parents, spouse, chosen family, etc.). This time is focused on identifying the client’s difficulties and what next steps are recommended by the therapist.

While holding these boundaries, Cross says it often helps to lead with compassion and remind her patients that a step-up to the right level of care “is not a win/lose situation” (where she wins, and the client loses). Needing additional support does not mean the client has “failed” or “lost” in outpatient care; it just means a different approach is needed.

While yes, making that initial call to an HLOC can feel so, so difficult, ultimately it can make all the difference for long-term recovery. Kate Gombach, an ERC alum, shares her experience taking that first step – and the relief that came with it.

“I remember being terrified to make the call and take that first step toward recovery,” Gombach shares. “It’s intimidating to call a stranger and admit your struggles. But I was reassured when they informed me that they were a clinician, and they showed clear compassion and understanding of my experience. I was honestly surprised by how relieved I felt by the end of that initial call.”

Tip 6: Know the benefits of higher levels of care

Each person’s path to recovery is unique. While there is no one approach that works for every person, there are a few factors that help us individualize your client’s care plan to best fit their needs. Entering an HLOC:

1. Creates structure: Individuals with eating disorders benefit immensely from structure. It can interrupt and reduce opportunities to engage in eating disorder behaviors while also integrating effective coping skills to manage eating disorder symptoms. When the intensity of eating disorder behaviors is beyond what your client along with their support network, family and friends can manage, then an HLOC is likely needed.
2. Addresses medical complications: Eating disorders adversely impact all organ systems in the body, potentially causing severe consequences. At times, your client may require intensive monitoring to ensure medical stability. When an individual with an eating disorder is medically unstable, HLOCs can ensure medical stability while also integrating psychiatric treatment. 
3. Provides more intensive therapy: Based on severity of symptoms, your client may require daily (or almost daily) intervention and opportunities to learn and practice coping skills to effectively manage their eating disorder. HLOCs offer your client multiple group therapies coupled with individual and family therapy, nutritional counseling and meetings with their psychiatrist to provide comprehensive treatment. 
4. Prioritizes safety: At times individuals with eating disorders may experience worsening depression and even suicidal ideation. When this occurs, HLOCs can provide increased support and observation to ensure your client’s safety.

As providers, it is important for us to be knowledgeable about the medical complications, levels of care and referral guidelines for patients struggling with an eating disorder. For more information and education on the treatment of eating disorders, we invite you to check out our no-cost, nationwide continuing education events (both live and on-demand). Learn more at EatingRecoveryCenter.com/professionals/education-events.

At ERC, we are available to partner with you and your client through our continuum of care model, which includes an integrated care system, progressive levels of support, collaboration across a multidisciplinary team and treatment that takes an individualized approach. Learn more about our treatment approach.

Tip 7: Connect with the right support

At ERC, we’re here to partner with you to match your client with the right level of support. You are an integral part of your client’s treatment team, and your experience working with the individual and their family system is invaluable. If your client is considering treatment with one of our programs, our multidisciplinary team will involve you throughout the admission process (and beyond, throughout treatment and discharge).

Connect your client to a no-cost assessment with zero obligation. There are four different ways you can make a referral:

1. Get in touch with our team at 1-877-825-8584.
2. Email us at [email protected].
3. Fax your patient's information to 425-974-1530.
4. Complete ERC’s online Quick Admit form.

Sources

1. Crawford, S. F. (2022, March). Guidance on levels of care for eating disorder treatment: How and when to refer. https://www.eatingrecoverycenter.com/sites/default/files/file/2022-03/ed-guidance-levels-care.pdf
2. Crone, C., Fochtmann, L. J., Attia, E., Boland, R., Escobar, J., Fornari, V., Golden, N., Guarda, A., Jackson-Triche, M., Manzo, L., Mascolo, M., Pierce, K., Riddle, M., Seritan , A., Uniacke, B., Zucker, N., Yager, J., Craig, T. J., Hong, S.-H., & Medicus, J. (2023). The American Psychiatric Association practice guideline for the treatment of patients with eating disorders. American Journal of Psychiatry, 180(2), 167–171. https://doi.org/10.1176/appi.ajp.23180001.
3. Norquist, G., Musher, J., Halverson, J., Pierce, K., Balfour, M., Schneider, M., Batterson, R., & Smith, T. E. (2020, April). APA Official Actions: Position statement on level of care criteria for acute psychiatric treatment. Retrieved January 2024. https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-Continuing-Care-Criteria.pdf.