Co-authored by Alyssa Reddi and Robert T. Muller, Ph.D.
“You know, we used to discharge people if they didn’t finish their first meal here.” That was the response from a staff member at an intensive eating disorder (ED) treatment program regarding patients being prematurely discharged from treatment–kicked out, that is.
The first time I was treated at an adult eating disorder treatment program, there was space for only 12 patients, and each of us had been treated before. Over the eight weeks I was there. I watched many of my peers leave early, either by choice or at the request of the treatment team.
Within intensive ED treatment programs, approximately half of all patients do not finish treatment. Among this group, it is estimated that half are patient-initiated, and half are staff-initiated. ED treatment is not an accessible resource for everyone, and many are unaware of this additional barrier to recovery.
In addition to dealing with an ED, many patients also struggle with other mental health issues, such as depression and anxiety disorder. ED patients may wait up to a year for a spot in a treatment program while dealing with physical or mental illness. Anne (name changed for anonymity), a former patient prematurely discharged from multiple treatment programs, shared her experience:
There are no other units in hospitals where patients are kicked out because their illness is too severe. To qualify for treatment in the first place, the illness has to be severe, and then patients are blamed for being frequent flyers.
There are only 21 intensive treatment centers across Canada, contributing to lengthy wait times and selectivity in treatment admission. We spoke to Blake Woodside, former medical director of 25 years for the ED program at Toronto General Hospital.
Woodside said the decision to terminate patients is never taken lightly and that patients may wish to remain in-hospital because they feel physically unsafe, weak, or at-risk. “But once they feel a little better, they discover that they’re not so ready to make changes.” He added, “The rationale for letting someone go early is the conclusion that the treatment simply is not working.”
Kaitlyn Axelrod is a social worker at Sheena’s Place, a community-based service in Toronto, Canada, that provides support to individuals affected by EDs. In an interview, Axelrod shared the insight she has gained from her experience:
Regarding reasons for being kicked out, some themes that have come up in the groups include engaging in eating disorder symptoms, engaging in substance use, and not showing enough motivation for change, or being resistant to treatment.
Anne has experienced staff-initiated termination many times due to self-harm during treatment and describes the consequences she suffered as a result:
Every time, my suicidality skyrockets. I scramble to figure out how to get home, or where I’m going to live, and I feel more depressed about my prospects of recovery.
EDs are notoriously difficult illnesses to treat. They have the highest mortality rate of all psychiatric illnesses and have a relapse rate of about 35 percent. Recovery requires tremendous effort from both patients and staff. So why is it that, even when there are good intentions, some patients are still told to leave treatment?
Woodside offered some insight. An important element missing from effective treatment is a lack of support for patients after they exit the intensive treatment system. “We shift people from 24 hours a day in the hospital to effectively nothing and have an expectation that somehow they’re going to do well. That doesn’t work.”
Another issue is how quickly patients are admitted into full-time programs. First-time patients go directly from the waitlist to intensive treatment without knowing how difficult the recovery process is. This can make it even more difficult for patients to follow restrictive rules.
“In an ideal world with unlimited resources, it would be great if treatment programs could meet all individuals where they’re at and not have to kick anyone out,” said Axelrod. But funding for ED treatment is and has always been limited.
Until more resources are provided and changes implemented, people with eating disorders will continue to face challenges restricting their chances of lasting recovery.
Copyright Robert T. Muller, Ph.D.