A day hospital program for anorexia nervosa and bulimia

A Day Hospital Program for Anorexia Nervosa and Bulimia

Niva Piran, Ph.D. Allan Kaplan, M.D. Ann Kerr, B.Sc. Lorie Shekter-Wolfson, M.S.W. Janis Winocur, M.Sc. Elaina Gold, R.N. Paul E. Garfinkel, M.D. (Accepted 22 November 1988)

A day hospital group treatment program is detailed which could offer effective treatment to many patients with anorexia nervosa and bulimia nervosa who would otherwise require inpatient treatment. The day hospital program can offer important clinical and financial advantages over an inpatient program. A major difference between the day program and an inpatient setting is the degree of containment offered to the patient and controf over the patient’s behavior. This necessitates important innovations. The day hospital treatment program includes psychological, social, and biological interventions. Most psychological treatment is done in groups. Staff use a multidisciplinary team approach. Potential pitfalls in the program include countertransference reactions and pathological group processes.

The documented increase in the incidence of eating disorders (Jones, Fox, Bobigan, & Hutton, 1980; Pyle et al., 1983) and associated morbidity and mortality (Theander, 1983, 1985; Garfinkel & Garner, 1982; Johnson & Berndt, 1983) make innovative treatment ideas a timely and important topic.

Niva, Piran, Ph.D., is an Associate Professor, Department of Applied Psychology, the Ontario Institute for Studies in Education and Senior Consultant, Eating Disorders Program, Toronto General Hospital. Dr. Piran is the past Clinical Director of the Day Hospital Program for Eating Disorders at the Toronto General Hospital. Allan Kaplan, M.D., is the Director of the Day Hospital Program, Toronto General Hospital and an Assistant Professor, Department of Psychiatry, University of Toronto. Ann Kerr, O.T., is the coordinator for group treatments, Day Hospital Program and a Lecturer, Department of Psychiatry, University of Toronto. Lorie Shekter-Wolfson, M.S.W., is the Coordinator of family therapy, Day Hospital Program and a Lecturer, Department of Psychiatry, University of Toronto. JanisWinocur, B.A., is a nutritionist, Day Hospital Program. Elaina Gold, R.N., i s a nurse, Day Hospital Program. Paul E. Carfinkel, M.D., is the Psychiatrist-ln-Chief, Toronto General Hospital and Professor and ViceChairman, Department of Psychiatry, University of Toronto. Address all correspondence and requests for reprints to Dr. N. Piran, Department of Applied Psychology, 9th Floor, the Ontario Institute for Studies in Education, 252 Bloor Street West, Toronto, Ontario, MSS IV6 Canada. International journal of Eating Disorders, Vol. 8, N o . 5, 51 1-521 (1989) CCC 0276-3478/89/050511-11$04.00 0 1989 by John Wiley & Sons, Inc.

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A recent trend in the treatment of anorexia nervosa and bulimia nervosa is the provision of more intensive treatment programs for outpatients that could be geared to individuals afflicted with the more serious forms of eating disorders. Vandereycken (1985) suggested the intensification of outpatient treatment of anorexic patients toallow for an earlier discharge from inpatient treatment. The transition involves outpatient attendance in the inpatient program. Mitchell, Hatsukami, Goff, Pyle, Eckert, and Davis (1985) described an outpatient treatment program for bulimia nervosa which involves the consumption of dinners, as well as group therapy, during the first 3 weeks of attendance. This paper presents a further development in the intensification of outpatient treatment for eating disorder patients. It describes an innovative day hospital program intended for the treatment of patients suffering from anorexia nervosa and bulimia nervosa who would otherwise require treatment as inpatients. This program, operating in a large teaching hospital, has been found to be effective in the treatment of both anorexia nervosa and bulimia nervosa (Piran, Langdon, Kaplan, & Garfinkel, 1988). The paper will describe the rationale for developing the day hospital program, outline the treatment program, compare the described day hospital model of treatment with the inpatient model, and discuss the limitations of the program.

RATIONALE FOR DEVELOPING THE DAY HOSPITAL PROGRAM We felt that the Day Hospital Program (DHP) would have several advantages over the traditional inpatient program. Financial

The DHP involves lower total costs per patient compared with an inpatient hospitalization (Dibella, Weitz, Poynter-Berg, & Yurmark, 1982; Herz, 1980). Moreover, a greater proportion of the cost could be directed to staff directly involved in patient care rather than to the "hotel" portion of a hospital. Availability

The DHP program can be available to more patients, both by being less costly and by its ability to accommodate a larger number of patients, without requiring additional facilities or staff (Dibella et al., 1982). Clinical

There are several clinical advantages to the DHP which could result in better outcome both during the difficult transition period immediately following discharge and in the long term. First, the day program promotes autommy and self-esteem. Mastering symptoms while off the unit allows eating-disordered patients to derive a sense of competence and attribute ultimate success, despite

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initial intense struggle and frequent failures, to themselves (Mitchell et al., 1985; Vandereycken, 1985). This sense of autonomy cannot occur during the early phases of inpatient treatment. Second, the day program facilities generafization of learning in that the patients have ample opportunity to exercise their newly learned strategies and insights with copatients in the program and with family and peers outside the program (Mitchell et al., 1985). Thirdly, the process of partial hospitalization limits psychological regression and hence controls transferences and countertransferences (Dibella et al., 1982). This regression can be a frequent problem for patients with eating disorders who often have concomitant serious character pathology (Piran, Lerner, Garfinkel, Kennedy, & Brouillette, in press).

DESCRIPTION OF THE PROGRAM Treatment Goal

The DHP is an intensive treatment intervention focused on the eating pathology and on significant biopsychosocial issues that impede the resumption of regular eating patterns. The therapeutic goal is the normalization of eating and related behaviors and psychosocial stabilization to allow for the patient to benefit from longer term outpatient individual or group psychotherapy. Working Hours and Capacity

Patients stay at the treatment center between 11:OO a.m. and 6:30 p.m. 5 days a week; they are provided with lunch, dinner, and snacks. Length of stay is 2-4 months. There are between 8 and 12 patients on the unit at any point in time. Patients are admitted in groups of three or four at the beginning of each month to facilitate group cohesion. Program and Group Rules

The day program has a set program and group rules which are essential in providing a framework for therapeutic interventions. This framework should be both containing and empathicially controlling. program and group rules are communicated to the patient at a preadmission assessment and again upon entry to the program. Program rules cover three main areas: essential working rules of the clinic, patients’ impulsive acts in and outside the clinic, and clarification of other avenues of help when the clinic is closed. Program rules related to impulsive behavior which occurs when patients are away from the clinic are important in helping patients control their impulsive acts. In impulsive acts we include eating-related behaviors such as unplanned dietary restriction, binging, purgng, and exercising and non-eating-related behaviors such as self-harm, alcohol and drug abuse, stealing, and lack of contraception if sexually active. Patients are asked to refrain from all these acts while in the program and to report deviations from these rules to the group and staff. By addressing directly the differ-

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ent avenues of tension discharge through impulsive action, symptom substitution is prevented. There is also an increase in the sense of containment, patients’ sense of integration is increased through grouping together different impulsive acts, and staff get an opportunity for close monitoring of patients’ progress. Patients’ discussion of any of these behaviors with the group is often the first step in achieving control. In the DHP, psychological treatment is offered in groups. It is therefore essential to include rules regarding group behavior.

Treatment Interventions

The program relies on biologic, social, and psychologic interventions. Biologic interventions include nutritional and medical stabilization and pharmacotherapy. Patients always start with a minimum daily consumption of 1500 calories. This calorie consumption is quickly adjusted to suit the caloric needs of each patient based on age, height, premorbid weight, or other factors such as continued propensity for overeating while in the program. Target weight range is set for anorexic patients or for underweight bulimic patients usually based on premorbid weight as has been described elsewhere (Garfinkel & Garner, 1982). Social interventions include occupational counseling, assistance in finding alternative living arrangements, and contact with community resources. Psychological interventions include family therapy and a variety of group treatments. Family and couple assessment and therapy is offered by our family therapist to all families. Other significant relatives may be involved, although the extent of involvement varies depending on clinical need and reality constraints. Involving all significant relations in the patients’ lives from the onset of treatment, at least for a clinical assessment, is important since partial hospitalization does not involve a physical separation. Psychological treatment is offered in groups. Patients are seen individually only for medical assessments, assessments of mental status, monitoring the indications and effects of medication, and for vocational assessment or planning regarding alternative living arrangements. All patients attend all groups. There are five to six groups daily. Every staff member is a cotherapist in at least one group, typically related to hidher area of specialty. This assures important involvement on the part of all staff members. There are important advantages to basing a day hospital treatment program on multiple group attendance. (1) Cumulative group attendance is a way to provide structure to a day hospital program and to increase patients’ sense of control and containment. (2) The presence of a copatient group 8 hours per day and the use of the “buddy system” during nonworking hours increases the sense of containment as well. (3) Extensive contact with copatients increases the power of group support, pressure, confrontations, and common problem solving. (4) Cumulative group attendance allows for the maximization of therapy contact within the allotted time. (5) Changes in patient census can be accommodated without corresponding changes in facilities or staff. (6) There is an efficiency in the use of staff time. (7) The presence of a peer group controls regression and helps diffuse transferences and countertransferences. (8) The

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group format help decrease patients’ sense of isolation and provides patients with opportunities for social learning. (9) Group treatment has been reported to be effective in treating some bulimics out of hospital (Connors, Johnson, & Stuckey, 1984; Lee & Rush, 1986; Schneider & Agras, 1985; Wolchick, Weiss, & Katzman, 1986; Yates & Sambrail, 1984). The group therapies are detailed in Table 1, where the treatment approach, the frequency, and the topics covered are specified for each group. The group therapies involve those which are directly related to the eating disorder and those which are directed at other deficits that these patients often display, namely difficulties with regulation of action, affect, self-esteem, etc.; difficulties in the interpersonal sphere; and difficulties with separation from the nuclear family. The treatment approaches employed in the group therapies are those which have been found useful in the treatment of eating disorders, addictions, and in the treatment of interpersonal difficulties. The psychoeducational approach (Connors et al., 1984; Fairburn, 1981; Long & Cordle, 1982; Garner, Rockert, Olmsted, Johnson, & Coscina, 1985) provides patients with information regarding their illness and a model which helps in accepting change as it occurs. Behavioral approaches involve self-monitoring, analysis and manipulation of behavioral antecedants, and relearning and the introduction of competing behaviors (Fairburn, 1981; Connors et al., 1984; Grinc, 1982; Smith, 1981; Mitchell et al., 1985, Long & Cordle, 1982; Mizes & Lohr, 1983; Lacey, 1983). The cognitive approach involves the reshaping of distorted cognitions related to eating behavior or self (Fairburn, 1981; Garner & Bemis, 1985). The “buddy system” is used in a similar fashion to its use with addictions, namely to encourage positive change through the use of group pressure and confrontations (Johnson, 1973; Mitchell et al., 1985). The “interpersonal learning” model described by Yalom (1985; pp. 19-47) is used to develop distortion-free relationships through self-observation, feedback, and corrective experiences in the microcosm of the group. Other specific techniques involve role playing or the use of sensory feedback as well as imagery in the body image group (Wooley & Wooley, 1985).

DAY PROGRAM STAFF There are seven full-time clinical staff. The staff include a psychologist, a psychiatrist, an occupational therapist, a social worker, a nutrionist, a psychometrist, and two nurses. The staff uses a team approach and, all staff are involved in group treatments according to their areas of speciality (nutritionist in eating group, etc.). Although the nurses and nutrionist are most often with the patients when they eat, all other staff cover meals on a regular basis as well. In that way, all staff carry important responsibility in caring for these patients. There are clear advantages to the team approach: all staff are involved and motivated; patients feel contained by a unified staff and splitting rarely occurs; the program is richer due to this multidisciplinary approach and the creativity of different team members; the team approach dilutes transferences and countertransferences; and the staff models group processes to patients.

X

day

Relaxations, imagery, behavioral, group pressure Behavioral, interpersonal

Body image group

Gym

2 x week

1 x week

Psychoeducational

Weight group

Behavioral, group pressure (addiction model) Behavioral, cognitive, group pressure (addiction model)

Educational group

1 X week (90 min)

2

Frequency (lengths)

1 x week before weekend (90 min) 1 X week (90 min) 1 x weekwhen weighed (60 min) 1 X week (60 min)

Behavioral, cognitive, group pressure (addiction model) Behavioral, group pressure (addiction model)

Treatment models

Psychoeducational, behavioral cognitive

A. Eating-related components Supervised meal and discussion Feedback on self-monitoring device Nutrition education and menu planning Eating group

Name

Table 1. Treatment g r o u p s a t t h e d a y hospital program.

Series of lectures of topics such as set point theory, risks of purging, drug/alcohol addiction, cultural pressures for thinness, etc. Difficulties around body image, distortions, pubescent changes, mood, etc. Not for excessively underweight patients. Exposure to healthy degrees of exercise which is allowed only in the program. Composed of group sports.

Alternative ways of coping with antecedants (events or feelings) Support with weight gain and identifying feelings regarding weight change.

Principles of good nutrition, portion sizes, weekend menu planning.

Problems with meal completion, underlying feelings, misconceptions regarding food Idenhfy achievements and difficulties, set new goals

Content

0

z

3 x week

2 x week

1 X week (90 min) 1 X week (90 min) 1 x week (90 min) When a patient is discharged (60 min)

Interpersonal

Behavioral, group pressure (addiction model)

Yalom’s High level In-patient Group

Psychoeducational, role playing

Psychoeducational, behavioral

Interpersonal, modeling, behavioral

Leisure and time management

Relationship

Family relations

Assertiveness

Good bye

X

Integration of good and bad experiences, and feelings regarding separation in context of group support.

Frame of the program, rules and norms, are tested and discussed. All patients and staff present. On Friday, a complete plan for the weekend is set involving new goals and risks. On Monday, discussion of actual events. Patients work in interpersonal agendas relevant to the here-and-now (Yalom, 1984). Topics include: role of the family, autonomy, separation, etc. Defining and exercising assertiveness

1

Behavioral

Cooking experience 8. Non-eating-related components Community meeting

week (60 min)

For advanced patients. Aids generalization and reestablishes social functions of eating. For advanced patients: cooking and eating the food

Behavioral, group pressure (addiction model)

1 X week (90 min)

Eating out

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There are, however, disadvantages to this approach. Blurred boundaries and role diffusion, part and parcel of the team approach, can result in tensions within the therapy team. There is also the risk that different interventions, especially if delivered by staff with different treatment approaches, will be working at cross purposes or be differentially valued by both staff and patients. A team approach entails more pressure on staff who are used to working in a heirarchical model to show more responsibility and initiative.

IMPORTANT DIFFERENCES BETWEEN THE INPATIENT A N D THE DAY HOSPITAL MODELS FOR TREAT1NG EAT1NG-DISORD ERED PATI E NTS Since the inpatient model of treatment has been previously described and widely employed (e.g., Garfinkel & Garner, 1982; Andersen, Morse, & Santmyer, 1985; Crisp, Norton, Jurczak, Bowger, & Duncan, 1985; Vandereycken, 1985), it is important to focus on core differences between the inpatient model and the day program model. In the inpatient setting, the patients initially are under complete external containment. In the DHP, patients are provided with important structure, including the provision of meals, in a special holding environment during the day. However, in the evening, morning, or on weekends, the patients need to exercise their own control over their maladaptive behaviors. In other words, the DHP expects change in highly cathected behaviors (eating symptoms) in patients with severe characterological deficits who habitually tend to express their conflictual issues through actions, without actually providing them with the comprehensive structure available on an inpatient setting. This important difference in containment and control necessitates the following innovations: 1. The operant behavioral components so frequently used on inpatient settings to promote weight gain, and requiring control of patient behavior, are not as useful in the DHP. These behavioral components are partially substituted in the day program by social support and social pressures through the group therapy format. 2. The day hospital patients require immediate “tools” (information, behavioral strategies, etc.) for maintaining control over their eating and eatingrelated symptoms and coping with difficulties handling unstructured time. Examples of such ”tools” include an eating self-monitoring device, comprehensive planning in the group of evening and weekend meals and other activities, exploration of alternatives to eating symptoms, and information regarding the risks involved with starvation, binging, and purging. 3. Since patients attending the DHP typically maintain their same living situations, dysfunctional areas have to be addressed from the onset of treatment so they will not impede therapeutic progress. These involve relationships, especially with families, living arrangements, and vocational issues. 4. Close monitoring of changes in mental state in order to provide appropri-

ate psychosocial or pharmacologic intervention is essential in a DHP. On the inpatient setting, the continuous hospital environment is an important containing element. In the DHP, containment relies more heavily on staff's provision of a holding environment. Periods of clinical destabilization require astute judgement and test the staff's skills in dealing with characterlogically difficult patients. This close monitoring requires extremely close cooperation and interaction among the multidisciplinary team. 5. The DHP offers psychological treatment mainly in a group format. Most inpatient treatments focus on an individual approach. As explained previously, the multiple group therapies format increases the containment of patients and patients control of their symptoms. 6. The patients' experience of being safely contained by the unit, even when away from it during weekends or evenings, is essential in their efforts to alter highly charged eating symptoms. This issue of containment requires deliverate planning in a day program, whereas it is less of an issue on an inpatient setting.

POTENTIAL PJTFALLS IN THE DAY HOSPITAL PROGRAM Possible pitfalls in a day program for eating disorder patients are presented below. 1. Staff Burnout: Countertransference reactions can be a cause of staff burnout. The most difficult countertransference reaction in the DHP is the staff's serving a holding function to these patients who tend to discharge conflict through action, especially when they are outside of the program. A second cause of staff burnout is the nonhierarchial team approach. For some, the team approach presents more demand in terms of responsibility and initiative. It is useful to hire people with long-term experience who have had the opportunity to work independently. 2. Pathological Group Processes: In a treatment program composed mainly of group activities, it is important to closely monitor group processes. If such pathological group processes as scapegoating, formation of cliques within the patient group, or negative group norms occur, it is important to immediately address these to prevent the exacerbation of symptoms, withdrawal, or dropout. 3. There is a higher risk for day hospital patients to engage in impulsive acts, other than eating symptoms, at least during the initial phase of their treatment. It is therefore important to try and contain all impulsive acts in the program, monitor patients continuously, and respond to periods of clinical destabilization. 4. In a treatment program where group treatment is the main form of treatment, individual contact with a staff member, especially the program directors, can have considerable unconscious meaning. This should be monitored by staff members and decisions regarding individual contact should be changed accordingly.

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5. Limits of Clinical Efficacy: This is an important issue for study when a new model of treatment is developed. Our initial outcome data reveal that the program is equally profitable for bulimic and restricting anorexics. However, patients who are not at all motivated to change will not benefit from a day program and can adversely affect the patient group. Patients under imminent medical or suicidal risk or those who are locked in a severely starved state cannot be treated in a day program. Patients seen at the day program show significant personality disturbance and benefit especially from a group program that can address more directly their interpersonal difficulties. However, a few patients cannot function in such an exclusive group setting and would do better on an inpatient setting with more individual contact. Examples would be a patient with psychotic-like paranoid reactions to the group or a patient with strong sociopathic tendencies who shows no attachment to the group. The response of heavy users of laxatives to a day program is being investigated. To conclude, we find the day hospital program to be an effective way of treating both anorexic and bulimic patients who require an intensive treatment program. It is important to further study the limitations of this treatment model. One such line of research is the identification of patients who would not benefit from the day hospital program and would require inpatient treatment.

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