When Is It Time for Inpatient Treatment Again for Anorexia?

By December 13, 2012

I have found I begin having dreams about being in inpatient and residential treatment centers at about the same time I am spiraling downward with eating disorder behaviors. The dreams are full of anxiety and fear. I’ve struggled with anorexia since age 10. I am now 32. I have been hospitalized multiple times. Most of my inpatient stays have been horrible experiences. I know I am in a dangerous cycle, but after all the treatment centers, therapy (I’m currently working with a therapist), feeding tubes (currently using one), nothing seems to help. I’m still stuck in the same patterns. I realize I still have a lot of unresolved trauma issues that my therapist says will take a long time to work through but we have made progress. I guess my question is, I’m getting a lot of help physically and mentally but I’m still going downhill. Multiple treatment centers don’t seem to have helped much. I do desire recovery….part of me….I’m trying, but I am extremely fearful. At what point is it time to start looking for inpatient or residential treatment again? Is it even worth the money if I could practically teach the classes myself? I have the intellectual knowledge. Do I just wait till the issues become eventually resolved and hope I don’t die in the meantime? I don’t know what to do anymore. – anonymous

Dear anonymous,

Your description of what you are going through is very well written and I am certain there are many others who can identify with the emotion that jumps off the page. My immediate reaction is one of sadness combined with a desire to come up with just the right words that will cause some tremendous breakthrough. However, in the many years I have had the privilege to work with girls and women with eating disorders I have come to understand that recovery is a process. That doesn’t mean that there are not times when recovery can take a quantum leap forward.

It sounds like you are working hard and that you are making progress with your trauma therapy. The fact that you have a feeding tube is more evidence of your earnest desire to get well. You are doing the right things. I want to address two aspects of your question: the idea of going back to an inpatient treatment center, and being stuck in the old patterns.

Let me start with the question about inpatient treatment. The following is a list of concerns that would strongly suggest admitting to an inpatient center. This is not an all inclusive list and it will be important to listen to the advice of your medical, nutritional and therapy caregivers.

  • You need to have a medical exam. Tell your doctor everything in terms of your eating disorder, and your eating disorder behaviors. He/she will need honest information in order to be accurate in their evaluation. Specifically ask if you are at imminent risk for a life threatening problem. Also ask, given what you are currently doing nutritionally (for example, caloric intake) – what is the probability that your medical condition will deteriorate in the coming weeks/months. NOTE: If your doctor states that you are currently at some medical risk, or that you are heading that way. You need to either go into an inpatient program for eating disorders, or at the very least, go into a medical facility to stabilize your physical health.
  • If you are thinking about suicide, whether that be active suicidal plans, or if you have a “if I die, I die” attitude with your health/nutrition.
  • If you are in significant emotional distress; inpatient can help alleviate that as well as taking care of other issues.
  • If you feel hopeless, feel like giving up, and are not taking adequate care of yourself.
  • If you and your therapist feel you are stuck in your therapy, inpatient can help. Inpatient can move you forward emotionally and physically so that your outpatient therapy becomes much more productive. Malnutrition makes it very hard to work in therapy, to concentrate, to remember, and to follow through on assignments. Malnutrition can also make medications (for example, antidepressants) you may be taking less effective. An inpatient stay can change that.  

Sometimes people feel that going back into inpatient treatment is a waste, because it didn’t work before or that they failed. I would like you to rethink the recovery process and see it as having various components that are meant to deal with different issues. For example, long-term outpatient therapy can help you deal with deep painful issues over a period of time. Inpatient has a different purpose.

I think of inpatient treatment as a bridge in the recovery process. Imagine recovery as a road, with some smooth places, some major bumps, hills, valleys, and deep and wide rivers. The recovery road is mostly outpatient, which should include both psychological therapy, working with a registered dietitian and regular medical checkups. But sometimes the road leads up to a deep river or gorge. You are stuck and can’t go any farther on the road (outpatient). The inpatient is a bridge that takes you across that river. On the other side, the road picks up (that is, outpatient treatment). Outpatient can move forward now because the bridge (inpatient) has helped you move across the gap.

Inpatient isn’t a cure; although people can come out of inpatient and be remarkably improved and become actively engaged in their lives. However, we always recommend that the outpatient continue because we know that the recovery road is an ongoing process. The bridge (inpatient) not only takes you across the river, but it can leave you off on the other side at a much better road of recovery with more efficient treatment and less bumps and valleys.

Now let me address being stuck in old patterns.

I am glad to hear that you and your therapist are making progress on your trauma, but want you to know, that the trauma issues do not have to be completely resolved before you can live in recovery. Recovery is one small step at a time. Eating disorders usually involve anxiety about food and weight gain. There may also be anxiety about relationships and becoming involved in work/school. Depression can also cripple us, keeping us from the vary things we need the most.

In terms of anxiety — there are two types of anxiety: 1) anxiety caused by a situation that is indeed dangerous, and 2) anxiety that is not caused by a situation that is truly dangerous, or the anxiety is way beyond any danger that may exist. With anxiety number 1 (real danger), the goal is to get out of the situation and become safe. The way to deal with anxiety number 2 (perceived danger, but not real danger) is just the opposite – you intentionally and willfully move towards the feared situation.

You can work with your therapist to identify cues and triggers that cause you anxiety. Try to make a list of a variety of triggers and rate how much anxiety each trigger causes (e.g., 1 is not much and 10 is very anxious).

Start with triggers/cues/situations that cause mild anxiety (a 3 or a 4) and intentionally face that situation – wait for the anxiety to go down before pulling away from the situation. For example, if someone were afraid of germs, her fear of touching a newspaper in a library may be a 3. She would go to the library and read (and touch) the paper rating how much anxiety she had every few minutes. When she felt the anxiety begin to fall off, she could put the paper down and do it again in a day or so. Once she is pretty much able to face one cue/situation without much anxiety, she moves on to the next. If the cue/situation causes extreme anxiety, she has started with something too strong, and needs to move down the list to something that isn’t as bad. Of course, incorporating the help of your therapist will be very important. But this will help you take back your life, even if it is only one small step at a time.

Concerning depression, one of our instincts when we are depressed is to isolate from people. Either we feel ashamed or maybe we simply don’t have the energy to deal with people. Even though isolating may feel better at the time, it makes things worse.

When you are depressed and want to shut the world away, push yourself to go somewhere and be with people, even if you don’t feel like it. Of course, it will be important to create opportunities for social/recreational activities ahead of time, as it will be very hard to come up with something on the spur of the moment. So, when you are feeling bad, don’t isolate. Do something, get active, again, even though it is very hard to do it. You can also force yourself to do this by, for example, taking a class that you are interested in at a community college, or taking lessons in something, even if you don’t believe you will every do it well. The idea is not to let the depression isolate you. The lack of social time and hobby time and fun time is not only a symptom of depression – it is a contributing cause.  Again take back your life one piece at a time.

I will leave you with this. Sometimes in psychology we get too focused on trying to make the bad things go away. We try to get the anxiety to go away, to get the depression to go away, to get the shame to go away, etc. But there is a key component we often miss.

Getting something to stop is important, but it is often much easier to add something positive than it is to stop something that is negative. When we are in darkness, we don’t try to grab the dark and toss it out – rather we turn on the light.

There is darkness and pain in your life – find points of light (church, hobbies, a class, friends, some volunteer work if possible, etc.) and embrace that light. Your mind likely drifts to the trauma and the ED thoughts. It is so hard to stop those thoughts – but by doing things and consciously giving your mind good things to focus on, there is less room for the dark thoughts. Finally, brothers, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable–if anything is excellent or praiseworthy–think about such things.

That last phrase, “…think about such things” isn’t passive – but rather it is a call to action – “choose to intentionally think about those things” — even when it is hard to do so and you don’t want to do so and you don’t feel like doing so – fight back.


David Wall, PhD