Podcast Transcript

Episode 31: All About the Levels of Care: Part 2

[Bouncy theme music plays.]

Sam: Hey, I’m Sam!

Ashley: Hi, I’m Ashley and you’re listening to All Bodies. All Foods. presented by The Renfrew Center for Eating Disorders. We want to create a space for all bodies to come together authentically and purposefully to discuss various areas that impact us on a cultural and relational level.

Sam: We believe that all bodies and all foods are welcome, we would love for you to join us on this journey. Let’s learn together.

Ashley: Hey, everybody! Welcome back to another episode of All Bodies. All Foods. Ashley and Sam are here and Sam, can you believe we’re already in season four of our podcast?

Sam: Not really. It’s hard to believe, these seasons have really, oh my gosh, everything just went by so quickly. But here we are, and we have more to say.

Ashley: We do! We have more to say and more to learn and all of the above.

Sam: Yes, more to say, more to learn. There’s more to come.

Ashley: Ya’ll, thank you so much for joining us again. We, this has truly been just such a privilege for Sam and myself to be on the show with you all and really to interview some of the coolest people and just connect with both our audience and with these professionals or alum in the community that have wanted to share their story. So, we just wanted to thank you all for that. Today, Sam and I wanted to come at you, again. We, in season three, we started talking about higher levels of care and what we realized in that episode is that we had a lot to say.

Ashley: Yes, we did! We had a lot to talk about and so we got through just part of it. Sam really detailed what it looks like to attend residential eating disorder treatment at The Renfrew Center. Today, I was going to share with you about PHP and IOP and I’ll explain all of these acronyms and letters and everything. But so, we wanted to continue that conversation. So, part two of higher levels of care is what we’re going to discuss today. How’s that sound, Sam?

Sam: That sounds great. And yeah, and if you haven’t listened already, go back and check out the residential level of care, which is only one level in the whole scheme of things. And it’s one of the highest levels. We have two sites, one in Philadelphia and one in Coconut Creek where you can get residential treatment. But we have all these other levels of care all over the country. So, we thought there must be so many people out there wondering: “What are the levels of care?”, “What is it like going there?”, “What can I expect?”. And we thought this would be a great opportunity to just go into more detail about what it’s like programming at these levels.

Ashley: So, I’ll start us off if that’s okay, just to even describe and explain what we mean by levels of care. So essentially, you know, if you’re experiencing an eating disorder, disordered eating, anxiety, depression, PTSD, all the above, any type of mental health you might be experiencing, you might go see what we call an outpatient therapist. That might be somebody that you’re connecting with once-a-week. With eating disorders support, specifically, what we notice is if you’ve been going to see a therapist once a week, perhaps you’ve even been seeing a dietician once a week or maybe twice a month, perhaps you’ve even been seeing a psychiatrist if you need help with some medicine management and what you are still finding is that you need more support. What you are still finding is that consuming food and managing your emotions is still challenging. That three meals a day is not happening for you, that your anxiety level, your depressive level, any of those that are getting heightened when you think about food. If you’re experiencing that, like you can’t go to different activities that you used to enjoy going to without getting so tremendously anxious or maybe isolating feels better for you. And so, this one time of going to therapy per week is not enough, I guess we would say. That’s when we might want to look into going into a higher level of care. Did that all make sense, Sam?

Sam: Yeah, I essentially, I think if you are in outpatient treatment and you’re not making progress and your whole team agrees that you’re not making progress or maybe you’re working on, let’s say you’re working on trauma, but your eating disorder is getting so much worse or maybe you’re working on your eating disorder, but your trauma symptoms are getting worse. You know, there’s so many different things that might be happening. That could be a sign that you would really benefit from more structure, more support, that you can find in those higher levels. And I think it’s confusing because there are so many different higher levels of care and it’s like an alphabet soup and I think a lot of people don’t even know what the acronyms are. I mean, I certainly didn’t when I started, I’m like, whoa, whoa, hold on. This is a lot. It’s like OP, PHP, IOP, Day Treatment. It’s like, whoa, whoa, whoa. So maybe we can just let’s go through the acronyms just so everyone knows what each thing means. So, you know, in our other episode, we talked about there’s residential programming that’s like 24/7 structure and support and supervision to help you break that cycle. That eating disorder cycle. That’s like one of the highest levels of care because you’re living there and you might be there for a month, two months, or maybe even more working on your eating disorder. And then eventually you step down to a lower level. Residential is not even the highest, the highest would-be inpatient care. That’s sort of like if you land in a hospital and you’re having some, you know, medical issues that need immediate attention, you might go into a hospital maybe for, I don’t know, a few weeks, maybe more just to sort of stabilize those medical symptoms. So, we have inpatient, also known as IP, that’s at the highest, highest level, then residential also known as RES and then as you step down, we get into the next one. So, PHP, maybe Ashley, you can talk about what PHP means and it also goes by other names and that’s where it gets kind of tricky.

Ashley: Yeah, okay. So, PHP stands for Partial Hospitalization Program. What I like to tell people, is that PHP is likely not at a hospital. That’s just the name. So, we also call it Day Treatment. So, PHP/Day Treatment, that’s essentially five days a week and I’ll get into more details with these, but just to walk through the different levels. So, PHP/Day Treatment, that’s five days a week from about 8 a.m. to 2:30 p.m.

Sam: Does it depend on the site?

Ashley: Yeah, it just kind of depends on the site, when it starts, when it ends. And then IOP is the level below that. IOP stands for Intensive Outpatient Programming. So, IOP tends to be three days a week and only three hours a day. And it can be during the day, it can be in the evening. Again, it just kind of depends on what the site offers, but also what you need. So, like some sites might offer their IOP programming as an evening program from 5 p.m. to 8 p.m. But if you need the Day Program, you can come during the day, it just kind of depends on your needs. It’s flexible. And then just to say again, Outpatient, so that’s typically when you’re seeing a therapist on your own once a week, but we also provide various outpatient groups. And so, what that would mean is you come to one group, one evening a week typically. And you’re doing that after maybe you’ve completed IOP and you’re doing the outpatient group and you’re doing, you know, therapy with your outpatient therapist. So that’s kind of the breakdown of the different levels of care. What I’ll say here is that when someone starts at RES, if that’s where somebody desperately needs that support, that structure, 24/7 care, the best thing to do if you can, is engage in this process. If you have the ability, the financial ability, the time ability to do this, then we would want you to do residential, then step down to PHP that five days a week care, then step down to IOP that three day a week care, then step into your outpatient group and go back to see your outpatient therapist. Does that all make sense, Sam?

Sam: Yeah, I mean, that’s the ideal scenario and I’m so glad you brought up accessibility because there are so many factors that can get in the way of someone being able to have access to those levels of care. But ideally, we like to think of the levels of care like a staircase and if you’re at the very top of the staircase that would be impatient or residential treatment and not to say you can’t skip steps, but it, it can be a little harder to go from the very top where you have 24/7 support, you have all these folks around you supporting you, not just the professionals, but the whole community and then to try to jump the whole way down to the bottom of the staircase. In my experience, I’ve seen folks, you know, that hasn’t been the easiest experience. And what can be really helpful is sort of developing a sense of mastery at each level of care. Like you feel like you’re running out of ways to challenge yourself. And that’s sort of the sign that it might be time to move on to a lower level where you have more free time, you have less supervision, you have less structure in your day and to see how you manage that and then mastering each level before stepping down to the next.

Ashley: And each level of care you’re going to have, you know, new challenges that you experience. But one of the things that Sam is touching on is that once you leave residential, you know, essentially you go back to your residence, you go back to your home, you go back to kind of where you’re stationed. And so, then when you’re able to do Day Treatment or PHP, which is five days a week, you’re able to be with a peer support group, you’re able to be with multiple therapists, with multiple dieticians, you’re able to be around this supportive team for five days a week, essentially, like I said, a school day, like six hours a day. That is so important, especially in eating disorder support and at Renfrew because if you are doing Day Treatment with us, you are going to engage in both breakfast and lunch with us in addition to all sorts of groups, which I can talk about. But those are so important because we need to practice engaging in those meals and not using the behaviors. And so, you’re going to have the structure of having support with you, essentially, like we said from 8 a.m. to 2 p.m., every single day. I can run through kind of what a day in the life of a Day Treatment might look like.

Sam: So, I’m curious. So, if I, let’s say I’m a new patient and it’s my first day of Day Treatment. Like I’ve never been to a program before, like maybe I’ve gone to my therapist’s office and that’s about the extent of it. What can I expect? Like I’m walking in the door, what’s next?

Ashley: So that’s a great question and, and I know one that honestly, a lot of our folks find themselves in, never having done this before. That’s so common to meet someone that’s never done this before. So, what you can expect is there’s kind of, there is an orientation period. We might walk you around the site, walk you around the center, show you the different rooms, show you the group rooms, show you the kitchen, kind of get you used to the layout of where things are.

Sam: A tour.  

Ashley: Yes, a tour, which can be really helpful, introduce you to some of the staff and then we’re going to start group. So, every morning at all of our locations, we engage in a mindfulness activity and mindfulness at Renfrew, we practice being in the present, we don’t judge our ourselves or our thoughts and we practice having simple awareness of what’s going on in the moment. So, we call it “present focus, nonjudgmental awareness”. We want to be in the here and now. And we really practice noticing what our emotional experience is in the moment and actively not trying to change it. So, if it’s your first day and your emotional experience is anxiety, perhaps feeling overwhelmed, nervousness, we’re going to ask you to label those thoughts. Notice what you’re experiencing in your body. Do you have butterflies in your stomach? Is your heart racing? Are your palms sweaty? And we’re going to ask you what your urges are. Do you have the urge to leave? Do you have the urge to greet everybody and tell everybody your name? You know, what are your urges? And we’re simply going to practice being there, being and existing in that space. And so, every day we have different mindfulness tools, different techniques that we teach. So, I, myself actually started at The Renfrew Center about six years ago and I was a primary therapist. So, I started at the PHP and IOP level at our site in Nashville, Tennessee. And I would lead people through the mindfulness activities. And so, we might notice just the sounds of the room, then we might expand that and notice the sounds outside of the room. What do we hear? Do we hear the birds chirping? Do we hear the cars going by? And then we might bring that back in. What do we notice internally? Do we hear our heartbeats? Um and things like that. So, we might notice sound, we might listen to music and notice if that distracts us. If it helps us, if it connects us, we just simply notice. Practicing mindfulness again, is just really that present focused nonjudgmental awareness. We might use lotion and notice the sense of the lotion. Notice how it feels to put that on our hands. All sorts of things. So various mindfulness techniques and I’ll say this about mindfulness. I love mindfulness. So, I talk about it a lot. But the goal is not to really erase your mind. I think sometimes we think that with mindfulness, but the goal is really mindfulness is a tool to connect us back to ourselves. So, it’s actually to acknowledge what is going on in our body. What are all the thoughts that might be racing? What is the, what is our experience that’s happening, you know, internally. So, we start with mindfulness and then we often leave as a group together and we go to breakfast. Your therapist, your dietician will be in there. They will be joining you with the meal, helping you process through it, if they need to give you some tools to use as you engage in the meal. And really, again, we’re, we’re going to ask you to kind of sit and be in the experience and notice if you’re having an emotional experience in the moment and kind of engage in the meal anyway. That can be really challenging, you know, and it can also be some of the most beautiful work. Our clients have peers that are in there as well. Everything is really kind of done in group work at The Renfrew Center. And so, they’re going to be able to get support from their peers or offer support if somebody else needs that.

Sam: So, I’m just curious, Ashley, if I, let’s say I’m sort of playing the role of the new patient coming into Day Treatment and let’s say I’m sitting down for breakfast for the first time and I’m looking at my plate and I’m thinking “I can’t do this”. How might the staff help me in that moment?

Ashley: That’s such a beautiful question. So, I think it’s really important to acknowledge that like we understand if you’ve never been here before this experience can be extremely overwhelming. So, we might likely explain to you what we’re going to do here. Like I said, we’re going to eat the meal with you. But I might say, “Sam, hey, I’ve noticed that you haven’t been able to touch your breakfast. I’m curious what’s coming up for you?”. And so, one of our tools, we’ve talked about it before, it’s called a three-point check, but one of our tools says we might engage in a three-point check. And so, it’s a mindfulness tool. So, I might say, “Hey, Sam, I’m curious, what are you thinking right now?”. So, Sam, can you label some of your thoughts if this is your first meal in treatment?

Sam: So, I, I would say my thoughts are “I can’t do this.”, “I don’t belong here.”, “I want to go home.”, “I’m not sick enough to be here.”

Ashley: Yeah. And so, I would hear that, and I would say, “Wow, I hear those thoughts and I’m wondering if you’re kind of experiencing some anxiety right now. It sounds like a lot of thoughts are telling you that you don’t want to be here. I’m curious, what are you feeling in your body right now?”.

Sam: So, I might say “I feel my heart racing.”, “My palms are sweaty.”, “I feel this lump in my throat.”, “I feel tense shoulders.”

Ashley: And do you have any urges to do anything right now, Sam?

Sam: I have the urge to run out of the dining room and go right in my car and drive home.

Ashley: Thank you so much for labeling all that. I can imagine how much pressure that feels on you right now. But I’m so thankful that you were able to label that and I’m curious if anyone else has ever felt that way or if you felt that way on your first day. And so, then I might ask the rest of the group who might give you some feedback as well and then again, I’ll thank you for sharing and I’ll ask if you could try to take a bite of your cereal or whatever it is we might be eating.

Sam: It could be so powerful, I think, to hear from someone else who might say, I had the exact same thoughts and urges two weeks ago and here I am, and I’ve made so much progress and that would be really cool to be able to, to talk to people who have already sort of and through the experience.

Ashley: I mean, you’re exactly right. And, and truly, that is why that relational piece is so foundational and fundamental to what we do at Renfrew and to how we do eating disorder treatment in general. Because a lot of times, when working with eating disorders, we often feel like we exist on an island by ourselves and no one understands it. And when we can have that direct support from somebody who actually does get it, I mean, that can mean the world to us and it can like, I might feel heard and connected with and understood for the first time and that is impactful.

Sam: I mean, that’s healing.

Ashley: Yeah, absolutely.

Sam: So, let’s say breakfast wraps up. What can you expect next? I figure what time is it by then?

Ashley: Maybe 9:30 a.m.

Sam: Okay. So, we still have the rest of the day in front of us.

Ashley: So, we have the rest of the day.

Sam: So, what happens after breakfast?

Ashley: Yeah. So, then we go often into a group and typically this is a psychoeducational therapy group where we talk about exploring our different emotions, we talk about what are the different emotions that we have. We talk about our thoughts. What are the different thoughts that we have? Can we reappraise or reframe those thoughts? We talk about just kind of all of this like emotional education, this kind of like cognitive process, educational stuff. What do relationships look like? How can we engage in relationships? We talk about family stuff, you know, so we might engage in one of those groups and then we have a break. And it’s just a very small break if somebody needs a snack, they can have a snack if we need to, you know, step outside and listen to the birds, we can do that and then we come back together and we engage in one of our experiential groups. And what I mean by that is, it’s, it’s kind of not a standard educational group. Like what I was just talking about, this group is more, it could be art, it could be expressive therapies. So, we might have an art group. We might have a group on body image or body trauma. We might have a group on nutrition. We might have that multifamily group. And so, what I mean by that is we actually invite our clients to invite their support system. So, every week the support systems are able to come in and do a group with each other and our clients and we do a lot of educational components for them, teaching them how to communicate together, teaching each person to advocate for what their needs are. We do a really cool group where we relate people to different animals. And you know, perhaps somebody is mama bear, perhaps somebody is a jellyfish.

Sam: Caregiver styles! We did a whole episode on that and by the way, if you’re wondering what does art have to do with recovering from an eating disorder, please go listen to our episode with Kyle Congdon all about art therapy and eating disorder recovery. And all these experiential sort of approaches that we have, psychodrama, we have an episode on that as well if you want to sort of do a deep dive on those.

Ashley: So, the experiential work is really critical because it kind of takes us out of the thinking brain. And it puts us in that “What do I feel in my core and how can I respond to this?” and, and we can actually get some really beautiful work out of that stuff. So, that is what we do. That’s the next group and then likely we go into lunch and lunch is going to be pretty similar to breakfast. Our meals are mostly prepared for us, but we’re going to be able to go back into the kitchen and kind of, you know, if we’re having a salad that day, put the salad dressing on or if we’re having burgers, like put the condiments on, you know, we’re going to be able to prepare that and then we go in the lunch room together and we talk about maybe what we’re experiencing currently in the moment. So, if you’re experiencing anxiety, Sam, if this is your first day and it’s lunch, we’ve already done breakfast together, but I might ask you on a level from 0 to 8. How high is that anxiety for you right now?

Sam: Probably say a six or a seven.

Ashley: Yeah. And then I might ask you and where do you feel that in your body?

Sam: Stomach, shoulders, throat.

Ashley: And then I might ask you, do you have an intention for this meal?

Sam: Oh, interesting. Right. So, maybe I would say I want to do, I want to have a little bit more than I did yesterday at home. Let’s say this was my first day.

Ashley: Awesome.

Sam: Yeah, maybe I just want to take it one step further, maybe have one more bite than I would usually have.

Ashley: And so, I would thank you again for sharing that. And I would acknowledge like your anxiety is pretty high and you were able to set an intention for this meal and that’s incredible. And so, we would go around the table and, and everybody would kind of answer those questions, then we would engage in the meal and again, we’re eating with the clients, you know, we’re eating with everyone. And so, they’re able to kind of see us engage in the same food that everybody else is engaging in. We’re carrying conversation, we’re talking, you know, and it’s not to say that these meals, I mean, these meals can be very challenging, so frequently we’re checking in with whoever is at the table with us. We’re asking what their thoughts are, what their noticing in their body, what their urges are. We might talk about, you know, whatever is going on. I remember having some meals and it was during the time of the Olympics. So, like every day we would check in about like, well, what was your favorite Olympic event to watch yesterday? You know, so we might even have casual conversation like that and then we do a check out, we might ask, what was a high, what was a low of the meal? And we acknowledge that like, you’re not going to, first of all, you’re not going to like everything, but you’re definitely not going to love everything. And that’s okay. We can acknowledge that collectively that we might all have different preferences and that’s okay too. And so, we’ll check out together and then we’ll go back for our final group, which tends to be, we call them review and process groups. And those are really times where we can come together at the end of the day, we can process the day, we can discuss anything that came up for us that day. Most of our groups have topics. So, there might be a day specifically where we’re talking about relationships and processing, relationally, what did you experience today? You know, things like that. There might be a group that’s talking specifically about communication. There might be a group on Fridays where we do weekend planning, you know, and all kind of talking about all of this because this is, you know, this is really a time and space for our clients to really just share with one another and get things that they need. It’s really a time for them to use their voice to advocate for their own needs and ask the questions that they need to ask. So, we call those review and process and they’re quite fun. I mean, we can, you know, we can really pull in any kind of resources and use all sorts of stuff for the, the ending group. But, yeah, that’s kind of what the day looks like. And then once that is over, typically, you’re able to leave or you may have a session with your therapist, your dietitian right after that.

Sam: Okay, so there’s still those individual appointments. I’m just wondering, how frequently do you meet with your therapist? How frequently do you meet with your dietician? What do those individual appointments look like?

Ashley: Yeah. So, in Day Treatment and PHP you meet with your therapist and your dietician every week.

Sam: Okay.

Ashley: If you’re working with the psychiatrist who’s on-site at Renfrew, then you might meet with them every week as well.

Sam: Okay. And how long are the sessions about, or does it depend on the site?

Ashley: They’re about an hour, maybe a little less. The dietician sessions might be half an hour. Usually in the beginning though, everything’s an hour because we want to make sure that you’re getting everything that you need. With adolescents, we’re also doing sessions with their family members. So, they might even have an additional session a week with their family members because we want to make sure that they feel as supportive as possible. Also, with our adolescence, we might do something that we call, “pull out meals” where we might have their parents come in for lunch or breakfast and then their therapist or dietitian, instead of that particular person eating with the rest of the group, they might eat individually with their parent and their therapist or dietitian, just so that the parent can also get some support and help in doing this at home because once you leave PHP, you know, essentially you have dinner at home.

Sam: And weekends, right? And so, you’re sort of managing all of the meals and it’s a good chance to practice to sort of use the tools that you’ve learned. I’m just curious, what kind of things might you work on with a family who maybe the clients really struggling to eat at home, but maybe they’re doing much better while they’re in program. How might you work with a family?

Ashley: Yeah, that’s a great question. So, we will give the family tools and questions that they can ask. So, for example, you know, I use the three-point check. We can definitely teach that to a family member. We want to teach the family member that they can hold space for the person that they love, that is going through eating disorder treatment. The person that they love, our client, they don’t have to answer everything perfectly. The family member doesn’t necessarily know how to recite proper emotional education. But if they can tell our client, their loved one, I can hold space for you, you’re allowed to be angry in my presence, you’re allowed to be happy in my presence. And that’s okay. I mean, that’s just so important, you know. So, we want to empower the family members as well. And so again, if they’re showing up for the multifamily group, they’re also gaining tools that way. And then if they’re showing up to do this kind of one-on-one meal coaching, they’re learning kind of what appropriate meals look like. They’re learning the right questions to ask and the and the wrong questions to ask too, right? Like we don’t want to shame anybody in this process. And it’s important that our clients nourish their bodies, right? Like that’s the biggest thing that they can take away from that meal experience is they want to get appropriate nourishment. And so, hopefully through all of these avenues, the families are getting tools to support themselves and their loved ones.

Sam: I’m so glad you brought up the caregiver styles. It’s sounds like it’s very much about teaching caregivers how to have more of those Saint Bernard and Dolphin moments.

Ashley: Yes. Can you remind us of those one more time, Sam? Which again, we do have the episode, but can you remind us?

Sam: Yeah. So, we have a whole episode on this and one of the first things we do, you know, I worked at the residential level of care and one of the cool things about all these levels of care is that we use the same treatment model. So, we’re using this same language. And so, as you step down, it’s all familiar to you and we’re all sort of on the same page. But, you know, a Saint Bernard is really an example of a caregiver or a partner, really anyone who cares about you in your life where they have this sort of calm, reassuring, patient, compassionate presence. You know, you think of that Saint Bernard who comes to rescue you out in the snowy wilderness and they’re just right there and they’re this steady rock that is loyal and loving and warm. And you know, you think of a dog, unconditional love, right? And it’s sort of like whatever you’re feeling, whatever you’re experiencing, I will always be here, I am always rooting for you no matter what, through all the ups and downs of recovery. That’s a Saint Bernard. And then the Dolphin is another caregiver style that’s very helpful where a parent sort of knows, they sort of learn, taking cues from their child or their partner when to sort of nudge them gently, you know, when to encourage them, but also when to let them lead the way and then also knowing when to, to maybe take charge and, and be the leader in a situation by modeling healthy emotional expression or modeling a healthy relationship with the body or with food. Just knowing those moments when you would be most helpful and how you can be most helpful. And we try to teach loved ones, caregivers, partners how to do that and when to do it and these are skills and like anything else, it takes practice and it takes time, it doesn’t happen overnight. But helping those families have those moments more frequently, more important.

Ashley: Right. And doing that at home, I mean, having those moments and having those meals, you know, families are likely going to say the wrong thing at times and knowing how to back up and apologize and kind of correct and offer a repair or a redo. I mean, those are so helpful too because messaging in the eating disorder world, I mean, we were talking about this before we even signed on the podcast Sam, but just the, the fatphobia and the messaging, I mean, it’s just all around us and it’s ingrained in us. So, there may be times when we say the wrong thing.

Sam: There will be, it’s inevitable.

Ashley: We get to do redoes and, and hopefully, those that are joining us at The Renfrew Center, our clients, hopefully they’re learning to use their voice too to also ask for that redo to say, “Hey, I don’t think that landed too well, or I would like to offer a suggestion here.”

Sam: Even if, we call these ruptures in relationships, even if a rupture happened years ago. You know, maybe something, some, you know, your, your parent or your partner said to you that your eating disorder sort of latched on to and to have that space to talk about those moments in a safe way. It’s sort of like when you said this, here’s how it impacted me, but then giving the loved one the skills how to repair that. And to do better. it’s so beautiful, so powerful when it’s like, yes, I messed up and I’m here now, you know. Yes, I was the Kangaroo back then. But now I want to be the Saint Bernard and I know how to do it. You, you guys must go back and listen to the Caregiver Style episode.

Ashley: I know I’m trying; I think it was maybe in season one.

Sam: It was, I think we did it early on.

Ashley: There’s a lot of good ones in season one because I think that one was in there and the one with our treatment model explanation – The UT Training with Melanie Smith.

Sam: Yes, all about the treatment model.

Ashley: Like those are super helpful. If you want to unpack more of what we’ve been talking about in this episode, but quickly, I also wanted to say in Day Treatment, what we also have are added groups that our clients can engage in. And what I mean is these are just additional groups that typically run like sometime in the afternoon. So, you might have somebody from PHP, you might have somebody from IOP in there. Some of these groups might be virtual. So honestly, you might be in group with people across the country, which I think is pretty cool. So, a couple of these specialty groups, one is Trauma and we call these tracks, so we have a trauma track. So, anybody that feels like that has been a part of their experience or that that is a diagnosable part of their experience, they can join the trauma track, just an additional weekly group for them. We have a substance use track, same thing, anybody that that’s been in their background, they can join that. We have a spirituality track and that can change depending on location. Meaning, that track might be focused on Christianity, it might be focused on Judaism, it can be focused on whatever it is that the client needs it to be focused on. Then the ones that are virtual, that kind of happen nationwide, we have a BIPOC track and so anyone that is a part of the BIPOC community can join that. And then we also have a SAGE track and SAGE stands for Sexuality and Gender Equality. So, anyone that feels a part of that community can join that track. So, we are trying to provide these supplemental groups to be available to all of our clients because we know treatment is not a one size fits all. Everyone has an experience; everyone has a story. And so, we want to accommodate the needs of our clients as best as we can.

Sam: I love that. And so, you can just hop on virtually at once a week and join those groups and have these smaller communities as part of your experience.

Ashley: Yeah.

Sam: I’m wondering, let’s say here I am a patient in Day Treatment. Let’s say I’ve, well, let me ask you this, how long is Day Treatment usually?

Ashley: That’s a great question. So, we work a lot with insurances and Day Treatment with insurance typically can run anywhere from like 4 to 6 weeks. So that mean you’re in Day Treatment for four weeks, five days a week, Monday through Friday, like I said, from that 8 a.m. to 2 p.m., frame. It can be up to six weeks. I mean, it can be as long as eight weeks. It’s really whatever you need, whatever you can work out, you know, accessibility-wise with your insurance and things like that, but typically it’s 4 to 6 weeks. When we’re talking IOP and quickly, I can kind of run through IOP as well, but IOP can run about 8 to 10 weeks. It can be shorter if needed or longer if needed.

Sam: So, let’s say I’m in Day Treatment and I am making progress and I’m meeting my treatment goals and how do I know, how does the team know when it’s, when we’re ready to move to IOP?

Ashley: That’s a great question. Okay, so you’re in PHP, let’s say you’ve been in PHP for five weeks, like you said, you’re meeting your treatment goals, which could be you are, you know, when you go home for dinner at night or over the weekends you’re engaging in your meals fully, you’re processing, you’re writing down your thoughts, even if you don’t necessarily enjoy that, you know, that your body needs to be nourished. You’re doing those things. Perhaps, you know, kind of a side goal, you’re working on reappraisals or reframing. So, you’re working on your cognitive thinking patterns, helping yourself reappraise. And what I mean by that is, let’s say, you know, you have a friend that you made plans with and they canceled last minute. And so, if we’re just kind of in the heat of the yuck, our thought might be, well, I suck. I’m not a good friend. Nobody likes me. Right? And so, I might ask you to reappraise or reframe that thought. And what you might say is, my friend had something else come up, but I am still a good friend. My friend genuinely had something that she had to go yo and that doesn’t mean that I’m a bad person. Does that make sense?

Sam: Yeah, well, learning how to think more flexibly, which is a skill that’s learned over time. One of the cool things about the UT is, is not only the skill of reappraisal, but really understanding what your core beliefs are that are driving a lot of the stories you tell yourself. And then once you start identifying that you’re walking around, holding on to these core beliefs, you start to realize, oh, this is why I keep telling myself the same type of story over and over again when this situation arises. So, it’s like these skills, but then also this insight of why you might be stuck in these patterns, you get stuck in these thinking traps and to be able to label it like, okay, that’s a thinking trap. I know what this is.

Ashley: So you’re, so you’re labeling those patterns that you’re stuck in, you’re labeling behaviors that you might go to when you’re emotionally heightened, you’re labeling this and perhaps you’re kind of walking in a different direction, you can acknowledge that that’s where you want to go and you’re moving in a different direction, which can be so helpful. So, when you get to that point and, and our clients often feel it, you know, our providers feel it. That’s when we say let’s start talking about IOP intensive outpatient programming. That’s the next step down. And so that’s going to be the three day a week for only three hours a day. So typically, that is one of the groups that I described, one of the UT groups, which is the psychoeducational group where we’re going to learn emotional um skills, cognitive, flexibility, skills, kind of things like that. So, we’re going to do that group, we’re going to do dinner if you’re coming in in the evening or lunch, if you’re coming in the day and then we’re going to do an experiential group. So, we’re going to do the body image, the expressive arts, the multifamily group, the nutrition group, and those kind of rotate because we only have three groups a week. So those kind of will rotate for you. So, someone in IOP will do those three hours a day and they will still meet with their therapist once a week, but they will go down to meeting with their dietician only once every other week. So, twice a month. And then at that point, if they have a psychiatrist in their outpatient world, we’re going to refer them back to their psychiatrist in outpatient. So they’ll be meeting with that person and which brings up, they can also start meeting with their outpatient team as well. Perhaps the therapist and the dietitian that referred them, they don’t necessarily have to do that because that’s, those are a lot of meetings, you know, on top of IOP, but they can start getting back into the groove of seeing their outpatient team. And so IOP, like we were saying earlier, Sam is the natural progression, the natural step down from PHP. You know, people are going to, they’re, they’re going to start experiencing a lot more freedom and less structure. And so really, really, really starting to put into place all of the tools and the skills that they have learned and that they have grown with over the last several months.              And then essentially, you know, like I said, anywhere from 6 to 8 weeks with that and then they would likely step into those outpatient groups where it might be, you know, a support group. Like an alumni support group that we might have and we typically have those locally, but we also have those virtually as well. Sam, I know that you lead one of our alumni groups.

Sam: I do, I lead the residential support group, which we have once a month, virtually, folks from all over the country join. As long as you’ve been in one of our residential programs, you’re welcome to join and its free forever. Once you’re a Renfrew. That’s one of the cool things about our alumni services, which fortunately I am able to participate in quite a bit because of my role here at Renfrew. But once you leave Renfrew, you have access to these things forever. And accessibility is such an issue in this culture. And so, I’m just so proud that we’re able to offer these things to, to our alums. So free support groups, free webinars, free reunions. The reunions are really cool because everyone sort of comes to reunions, workshops and we get to kind of see how everyone’s doing. But yeah, so this was so helpful, Ashley. I, and I really hope this was helpful for our, our audience because I know there are so many people curious about what would it be like if I did go to an eating disorder program, what can I expect. And hopefully this sort of demystifies the whole process.

Ashley: And like I mentioned earlier, it’s not a hospital. We are humans too, we’re with you. We’re walking you through the process. I mean, truly, you know, the staff that is there, the clinical staff and anybody that’s there, we are there to support you. And, and the, the support that you also receive from your peers that are also in the program, it’s invaluable, I mean, and it is just so validating to hear that somebody else might be having an experience similar to yours, slightly similar to yours, completely different from yours, but you’re all here together. It can just be so healing.

Sam: Oh, absolutely. I think, you know, I just want to add also that, you know, we talked a lot about the UT and the stages, but also how individualized things are in treatment, whether you’re someone who is neurodivergent or you’re, you know, you occupy a marginalized identity, like everything is sort of seen through the lens of anti-oppression. We really try to individualize things and make accommodations for folks who, who may need accommodations, whether it’s neurodivergence or some other thing. So, I wanted to point that out that it’s not a one size fits all. You know, I know we talked a lot about the different skills and, and some things about the UT that we teach, but also we take into account the individual and what makes sense given the individual’s needs. So, I think that’s so important. I just wanted to mention that.

Ashley: I love that you said that, I mean, I just couldn’t agree with you more fundamentally at Renfrew. I think we do our best to honor each individual’s experience and, and we are constantly learning and growing, and I think when we, when we recognize if there are blind spots, we work on that. We’re not perfect, right? I mean, everybody has blind spots and I think that our heart is to work on that, and our heart is to show up for our clients and to be a place of healing for them. So that, that is truly, I think fundamentally where we are with our treatment as well.

Sam: I agree. Thank you so much, Ashley.

Ashley: Thanks Sam. This was awesome. And you all, thanks again for being with us today. We hope that this was helpful.

Ashley: Thank you for listening with us today on All Bodies All Foods presented by the Renfrew Center for Eating Disorders.

Sam: We’re looking forward to you joining us next time as we continue these conversations.

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