Dr. Yong Lee
Director of Psychiatric Services at Remuda Ranch
As a psychiatrist in private practice in the community, I enjoyed engaging with my patients in problem solving. I would tell them it is a brave first step to take. You could have continued living with your problem, but you were brave enough to see that you couldn’t do it on your own. Getting better is a collaborative process. Let’s work together to find a solution to what’s bringing you in. I loved what I did. It gave me enormous satisfaction when my patients were able to overcome their depression, stabilize their panic attacks, stop their drinking, get back to work, reconcile with their spouse. Now this approach works in most clinical situations, but my patients with eating disorders were definitely a special population.
In an ideal world, we as behavioral health providers, dietitians, physicians, therapists, and counselors—all want to do what’s best for our patients, and it frustrates us when we can’t meet their needs. I’m a firm believer of practicing what you preach. If our patients are seeking help for a problem that they cannot overcome, I think there is no shame when we have to admit that are patients are not doing well in an outpatient basis and that we need help. Eating disorders, at least in my experience, cannot be well managed in isolation; it usually requires a team approach, usually involving a therapist, dietitian, primary care provider, and possibly a psychiatric provider, such as myself. A team approach is what attracted me to working at Remuda Ranch as an inpatient psychiatrist.
What I recognized, after years of practice, was when a behavior is life threatening, the priority needs to be to do whatever it takes to stop the behavior. This may involve removing the patient from factors that maybe fueling the behavior, which may include peers, school, work, and even family. This may be incredibly painful and disruptive, but the ultimate goal is to disrupt the eating disorder, not school, work, or family life. These are all good things the eating disorder threatens to destroy.
When a patient with anorexia nervosa is severely malnourished--to the point of causing the patient's body to shut down, bones to become leached, blood pressure to fall, and the mind to shut down—the first thing needs to be medical stabilization. This requires an intense, highly controlled setting with the ability to closely watch the patient's vital signs, perform laboratory blood tests to monitor the patient's electrolytes, EKGs to monitor heart function, and, when absolutely necessary, nasogastric tube placement that will allow us to nourish the patient through tube feedings when the patient is unable to meet her nutritional needs any other way. This cannot be done in a less intense setting, without risking the life of the patient.
We should also be aware of the dangers associated with eating disorders involving self-induced vomiting as seen with patients with bulimia nervosa and a subset of anorexic patients. In fact, it is the anorexic patients that purge by vomiting who are at the highest risk of death by multi-system organ failure or sudden death from cardiac malfunction caused by electrolyte imbalances of low potassium, magnesium and phosphorus. The close medical monitoring involved is found at an inpatient level. These patients need hospital care in a hospital. The less intensive care of a residential setting would not provide this level of care.
Refeeding the patient also comes with risks. In a patient that is severely malnourished, the body is in a semi shut down mode. The organs have shrunk. Blood pressure and body temperature is low. Menses has stopped. The body must be fed very carefully, gradually, with close medical monitoring to avoid sending the body into shock, which we refer to as Refeeding Syndrome. Weight restoration, although it is necessary and life saving, if not done properly in the correct setting, can inadvertently endanger the patient that it was meant to save.
What about those clinical situations that are not as extreme? What about the majority of patients that are not in imminent danger of dying? Isn't inpatient care overkill? My response, of course, is that it depends on the patient's unique clinical situation. If the patient's eating disorder is out-of-control and threatening to destroy a patient's health, relationships, education, employment, and will to live, my question would be why take a chance? Overkill sounds pretty good to me. At least you know you are doing everything you can to stop the behavior.
If a patient is absolutely determined to engage in her eating disorder, an inpatient setting might be what's necessary to break down the control the eating disorder has on the patient. By design, an inpatient setting is a controlled artificial environment. Patients are told what they may wear, where they are to sleep, when the have to get up, what they are expected to eat and so on. Sure they complain. They hate losing control. They hate getting up so early. They hate being away from work, school, and their families. Why do they have to finish their meals? Why do they have to go to groups and talk about their feelings? Why do they have to do the therapeutic exercises and assignments?
Eating disorders are about many things; one of them is control. The patient with an eating disorder is controlled by an elaborate system of rules that are even more stringent than any inpatient unit. These eating-disordered rules tell them they can eat this food and not that food; they are allowed to only eat during this time of the day; if they do eat, the food must not touch, must be cut into small portions, must be eaten in this order; they need to exercise this amount of hours, run this many miles; that they only need to lose 10 pounds to feel better about themselves. The patient with an eating disorder has organized her life with such an elaborate system of rules that once you take them away you need to substitute them with another set of rules: three meals a day with snacks; moderate exercise; communicating with words, instead of an eating disorder; socializing with peers and family, rather than hiding in your room.
Over time, the rules and the structure of the inpatient unit becomes a source of comfort. Often it’s the case that the patients who complained the most about rules and regulations of the unit in the beginning, are the staunchest adherents in the end. They are the ones who get upset if equine therapy starts five minutes late. They are the ones getting their peers up in the morning and on to the unit so that breakfast starts promptly on time. They are the ones who want to know when their weekly schedules are printed up. They are the ones who show their new peers where everything is and how things are done at Remuda Ranch. Instead of talking about their eating disorder, they are talking about how excited they are to see their friends and family. How they can’t wait to get back to school, to get back to life in the real world. I’ve compared having an eating disorder to being in an insidious cult that promises you happiness, fulfillment, and meaning; but instead it delivers loneliness, emptiness, and death. Remuda Ranch is here to give you back the life you were always meant to have.