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Article Excerpt
The provision of psychological treatment within the community is becoming increasingly important as time and resources become more scarce. Nowhere is this challenge greater than when undertaking the treatment of eating disorder clients in a community mental health setting. In this paper, we outline a multi-faceted treatment approach to eating disorders within a partial hospital program that is affiliated with a community mental health hospital. Although empirical confirmation is not currently available, initial clinical impressions indicate that the program is facilitating the recovery of these difficult-to-treat individuals.
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Practitioners working in community mental health settings are finding an increasing number of clients who present with eating disorder symptoms (Hoek, 1995). These clients may exhibit a wide variety of symptom constellations (Brownell & Fairburn, 1995; Garner & Garfinkel, 1997; Hsu, 1990), including concomitant medical complications (Mehler & Andersen, 1999; Mitchell, Pomeroy, & Adson, 1997; Powers, 1997), comorbid psychological conditions (Edelstein & Yager, 1992; Strober & Katz, 1988), personality disorders(Swift & Wonderlich, 1988; Wonderlich & Mitchell, 1992), impulse and substance abuse problems (Johnson & Connors, 1987; Mitchell, Pyle, Specker, & Hanson, 1992), and self-injury as well as pathology related to sexual abuse (Levenkron, 1998; Schwartz & Cohn, 1996; Vanderlinden & Vandereycken, 1997). In addition, evidence suggests that in a number of weight-tolerant cultures (Garner, 1997), eating disorders are increasing in prevalence among children and adolescents (Lask & Bryant-Waugh, 2000) as well as males (Andersen, Cohn, & Holbrook, 2000). Given these findings, clinicians are often faced with the provision of services to profoundly psychologically and physically debilitated individuals (Levitt, 1998, 2000a, 2000b).
Eating disorder clients generally require intensive and often extensive treatment in order to return to effective functioning. These clients access and utilize multiple services in community mental health settings, including outpatient treatment and hospitalization. Yet, treatment services must be delivered more effectively and efficiently than before due to limited resources (Levitt, 1998) and must be therapeutic, grounded on practice guidelines (Hayes, 1999), and evidence-based (Wade, 1999). As a result, the need for well-executed and sequenced treatment has become essential (Garner & Needleman, 1997).
To complicate the delivery of services, changes in availability of levels of care in community mental health settings have also occurred, with hospital services perhaps being most affected. Inpatient hospitalizations are generally limited to several days and utilized only for purposes of acute stabilization. When achieved, the patient is transitioned to a less intensive level of care such as partial hospital or outpatient treatment. For eating disorder clients, crisis intervention often only serves to intervene with the most deleterious effects of the disorder, not to directly address eating disorder pathology. Unfortunately, many eating disorder clients exhibit an acute-chronic (i.e., intractable) pattern (Yager, 1995), and brief inpatient stays are unable to effectively stabilize symptoms. As a result, partial hospitalization programs for these clients have become increasingly utilized (Kaplan & Olmsted, 1997). Partial hospital programs may be the preferred setting for the treatment of eating disorder clients because they are a less expensive means for providing various services to potentially difficult-to-treat individuals (Kaplan & Olmsted 1997; Kaplan & Spivak, 1996; Levitt, 1993). In these programs, clients attend the partial hospitalization program during the day for a varying number of days and spend nights at home. The managed care review criteria that are utilized for inpatient treatment programs often extend to partial hospitalization programs.
However, practitioners in community-based partial hospitalization programs are faced with two major hurdles: (a) incorporating best-practice models of treatment and (b) evaluating the outcomes of those treatments. The literature on the treatment of eating disorders supports the utilization of a multi-dimensional perspective (Garfinkel, 1996; Garfinkel & Garner, 1982) with an emphasis on empirically confirmed interventions such as cognitive-behavioral approaches (Fairburn, 1997; Garner, Vitousek, & Pike, 1997; Johnson & Connors, 1987), psycho-educational and nutritional approaches (Beaumont & Touyz, 1995; Garner, 1997; Weiss, Katzman, & Wolchik, 1985), family therapy (Honig, 2000; Minuchin, Rosman, & Baker, 1978), and interpersonal psychotherapy (Fairburn, 1997). It is also recommended that interventions be tailored and sequentially implemented on an individual basis (Andersen, 1985; Garner & Needleman, 1997).
With regard to evaluating treatment outcome, clinicians face significant obstacles. As examples, clients rapidly enter and leave treatment, often present with multiple Axis I and II diagnoses, and frequently terminate treatment prematurely, thus making outcome evaluation difficult. In addition, treatment providers are often the same individuals who must evaluate the outcomes of services (i.e., dual roles). Outcome evaluation requires tools that are...
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