You have been seeing an outpatient client who is recovering from bulimia and you notice that she has lost a significant amount of weight over the past several weeks. She tells you that her appetite has not been what she is used to, but that she is sure that it will "pick up again soon". In the weeks to follow, you attend to several comments that she makes in passing about "liking my new size". She seems to have trouble staying focused in session and she looks very tired. She assures you, however, that she is not purging and offers, "I think that I am just less hungry since I started running more".
The red flags are there...
Should you step up the level of care for her treatment? Is outpatient psychotherapy still sufficient? How do you know when a more intensive form of treatment is appropriate? Would a decision-tree be helpful?
Fortunately, The American Psychiatric Association recently updated their practice guidelines for eating disorders treatment. In addition to "best practices" information, the guidelines include a helpful reference for use when making level of care decisions. Medical stability, social support, intensity of symptoms, motivation, and co-morbidity are some of the factors to consider when recommending an appropriate level of care for a client. A patient & caregiver handout with similar information is available from the National Eating Disorders Association. You can buy the complete set of ApA practice guidelines in print, or download a pdf version for your professional use.
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