With the publication of results for models of family-based home treatments, the treatment of children with eating disorders has changed a lot in the past five or six years, or at least it has in many communities. In some places,however, it is still the “same ol’, same ol’” of individual eclectic therapy, nutritional advice and a doctor’s infrequent monitoring - a combination known for some time to give substandard results.
For some patients “Maudsley” and other forms of newer outpatient family-based treatments have been a blessing; not only are they more successful than older treatment paradigms, but they are based on the critical observation that parents are NOT the problem. In fact they are an essential part of the solution.
Yet outpatient treatments, even the very best, do not work in all circumstances. They can be very demanding physically and psychologically; often one parent has to quit work and keep the child at home all day, or whatever it takes to get enough food down them to stop the weight loss. Bingeing and purging, if present, must be strictly prevented with hawk-like, round-the-clock supervision. At the other end of the treatment spectrum is “residential treatment”, where children must leave their hometown or state (in many cases) to attend treatment on their own, without the daily input of their parents, and often at large hospital-based mental health centers. Don’t get me wrong: residential treatment can be life saving, but the lack of family input inherent in the very nature of this style of treatment makes it less than optimal. So what’s in between?
Patients whose parents have successfully re-fed them on their own and who then have gone on to reclaim their lives usually do not make it to Kartini Clinic, as we would have little to add. And an occasional child is brought to us at an early enough stage that our outpatient treatment program and regular school attendance is still possible, but the majority of our patients need more, and that is where the Day Treatment Unit model (DTU aka “partial hospitalization” in the insurance world) comes in.
DTU at Kartini Clinic was initially conceived as a “step-down” unit for those children who began their treatment in the hospital because of medical instability. Once stable, patients are “stepped down” to our DTU, where they spend the day, and return home to their parents at night and on the weekends. Of course this means regular schedules are disrupted, especially school, so we retain a private tutor to keep children in contact with their teachers and up to date on their schoolwork. Most of our patients (and parents) really care about schoolwork, and so do we.
But DTU is more than just a step-down on the way to outpatient. Some children and young adults are medically stable and can enter DTU from day one. They’re able to tolerate food, with assistance, and to eat in a family-like setting. DTU is a mental health setting where, with the help of therapists, our children learn to eat again in a social setting, and manage their feelings about doing so. We also teach the family to continue this food-based healing at home. Anger, acting out (ask the parents who have tried this on their own!) and anxiety attacks are managed by therapists who can not only cheerfully “take the heat”, but help the kids work through it. Both parents can usually return to work (unless they’ve had to travel to Kartini for treatment, in which case one parent must stay with their child), school work is taken care of, and the doctors help steer the course when it comes to weight restoration goals and medications, if necessary. Families who must come from out of town or even overseas stay at the Ronald McDonald House (virtually next door to our clinic) and learn to make the transition to home and outpatient treatment. We like to say that our treatment is for those who want a life, not an eating disorder.
The intensity of the DTU model, we feel, shortens the time needed to achieve weight restoration, and sends the message loud and clear that parents are essential team members who work together with family therapists and physicians under one roof on such things as food preparation, planning, weight restoration and re-socialization. Parents also attend parent support group where they complain, laugh, cry and give each other tips. Once the patient is ready to graduate from the DTU the family can be ready to take over all necessary meal preparation and supervision, and the child to return to a full day of school.
When our kids graduate to outpatient status both they and their parents are ready to be outpatients. This has greatly diminished the need for repeat hospitalizations or referrals to residential treatment. It also underscores our basic message: parents don’t cause eating disorders and children don’t choose to have them. Tired of hearing me say it? Try life (and treatment) without this concept and you’ll see what I mean.