Day hospital programmes for eating disorders: A review of the similarities, differences and goals

Vol. 14: e31-e41, June-September 2009

e31

REWIEWARTICLE

Key words:Anorexia nervosa, bulimianervosa, eating disorders,day treatment, day hospital,partial hospitalisation.Correspondence to:Prof. Secondo Fassino,Neurosciences Department,Psychiatry Section,Via Cherasco 11,10126 Torino.E-mail:[email protected]: March 12, 2008Accepted: December 5, 2008

Day hospital programmes for eatingdisorders: A review of the similarities,differences and goals

INTRODUCTION

In the last years eating disorders (EDs)have received greater attention because oftheir diffusion (1) and social and healthcosts (2, 3).

Currently, treatment of EDs is performedin outpatient, inpatient and day hospital(DH) settings without a shared knowledgeabout the best and most effective treatmentfor each patient (4). Further studies arerequired to clear this issue, specially asregards DH treatments.

DH treatment usually involves medicallystable patients who require intensive treat-ment with frequent contact and involve-ment in groups, as recommended by theAmerican Psychiatric Association guide-lines (5) and the National Institute forHealth and Clinical Excellence (NICE) (6).

The DH has unique characteristics: inten-sive daily care is provided but, unlike inpa-tient units, patients return home and main-

tain their social relations, allowing a dailytest of the improvements made and a pro-gressive work on environmental risk factors.

Although DH treatments are widespread,their description in the literature is lacking,except for the pioneering descriptions of theToronto (7) and Munich programmes (8).

Recently, Zipfel et al. (9) and Lammers etal. (10) reviewed the international DH treat-ment programmes for EDs, underscoringtheir advantages and disadvantages.Nonetheless, these reviews have several lim-itations: Zipfel et al. (9) describe only threecentres and Lammers et al. (10) underscorewith more detail the similarities than the dif-ferences of the different models of care.

The first aim of this review is to comparethe different types of DH programme fullydescribed in the literature and to discusstheir similarities and differences. The sec-ond aim of the article is to describe our DHexperience in Turin, Italy, and to compareits features with the other centres found.

G. Abbate-Daga, C. Gramaglia, S. Preda, E. Comba, A. Brustolin, and S. Fassino

Eating Disorders Centre, Neurosciences Department, University of Turin, Turin

ABSTRACT. Day hospital (DH) treatments for eating disorders (EDs) provide intensive dailycare and allow patients to maintain and test their social relations and coping skills at homeand outside. Although widespread, their description is lacking. This review compares the dif-ferent types of DH described in the literature and presents our DH experience in Turin, Italy.We searched Psychinfo and Pubmed with the following keywords: anorexia nervosa, bulimianervosa, EDs, DH, day treatment and partial hospitalisation. We found and reviewed the DHprogrammes of eleven specialised centres, which have some shared features but also manydifferences, suggesting that DH treatments are still largely experimental. Briefly, the sharedelements are: biopsychosocial model as reference frame; cognitive-behavioural model ortechniques; behavioural contract; patients’ selection; body image therapy; involvement offamily; weight normalisation/weight gain and modification/normalisation of eating behaviouras objectives. Nonetheless, shared opinions concerning inclusion criteria are lacking; theduration of DH treatment is surprisingly different among centres (from 3 to 39 weeks); theapproach to eating and compensation behaviours ranges from control to autonomy; follow-up and psychometric assessment can be either performed or not; psychological and behav-ioural objectives can be different. This review suggests the existence of two different DHmodels: the first has a shorter duration and is mainly symptom-focused; the second is moreindividual-focused, has a longer duration and is focused on patients’ relational skills, psycho-dynamic understanding of symptoms and more gradual changes in body weight. Furtherinvestigation is required to make DH treatment programmes measurable and comparable.(Eating Weight Disord. 14: e31-e41, 2009). ©2009, Editrice Kurtis

G. Abbate-Daga, C. Gramaglia, S. Preda, et al.

MATERIALS AND METHODS

We searched the literature using Psychinfo(1980-2007) and Pubmed (Medline 1980-2007),with the following keywords: anorexia nervosa(AN), bulimia nervosa (BN), EDs, DH, day treat-ment and partial hospitalisation. We limitedour search to articles in English and to adultpatients. The reference list of the suitable arti-cles was checked to identify additional interest-ing studies.

Overall, we found 20 articles (two of thesewere reviews) and 13 centres fully describingtheir treatment programmes for EDs. Three ofthem were excluded: the Bern Day Treatmentbecause the article was in German (11); theLeicester Day Programme Treatment (12)because the description of the DH treatmentwas too limited; the Victoria article (13)because it was only a letter to the editor andtherefore too limited.

This left 10 centres:- Day Hospital Program (DHP) of the Toronto

Hospital in Canada (9, 10, 14);- Treatment Centre for Eating Disorders (TCE)

in Munich, Germany (8, 9, 10, 15);- Our Lady of the Lake Eating Disorders Pro-

gram in Baton Rouge, USA (9, 10, 16, 17);- Eating Disorder Program (EDP) in Hoffman

Estates, USA (10, 18);- Cullen Centre (CC) in Edinburgh, United

Kingdom (19);- Amarum in Zutphen, The Netherlands (10);- Oxford Adult Eating Disorders Service

(OAEDS) in Oxford, United Kingdom (10, 20);- Day Clinic Programme (DCP) in Freiburg,

Germany (21);- Day Treatment Programme (DTP) in Chonan

City, South Korea (22),- Wesley Private Hospital (WPH) in Sydney,

Australia (10, 23, 24).Three papers (25-27) about the Day Clinic

Programme in Freiburg and the Day Treat-ment Programme in Chonan City wereexcluded because in German and Korean,respectively.

THE DAY HOSPITALPROGRAMME OF THE EATINGDISORDERS CENTRE, TURIN

The DH of the EDs Centre of Turin Universityopened in July 2006 and is part of a more thor-ough treatment programme, including alsooutpatient and inpatient care.

DH treatment has a bio-psycho-social frame-work with psychodynamic orientation. Psycho-dynamic group therapy, with an open structureof groups, and Adlerian individual psychother-apy (28-30) are the main treatment tools (Tables1 and 2). The psychodynamic groups encour-age patients to examine their interpersonalfunctioning, inner problems and the psychody-namic meaning of symptoms. Cognitive-behav-ioural techniques are used in a group setting tohelp patients in developing strategies to chal-lenge their irrational cognitions and exploringalternatives to their unhealthy behaviours (31).

The DH of the EDs Centre of Turin Universityfollows a single model (the psychodynamicone) and combines different strategies and pro-cedures. Being based on a psychodynamicmodel, the specific therapeutic agents are notthe core symptoms of EDs, but instead relation-ships, the individual’s personality and the clas-sic psychodynamic tools (clarification, con-frontation, interpretation). The advantage ofadopting broad tecniques versus a morefocused treatment is the possibility to plan indi-vidualised care, avoiding the well known risksof clinical trial in EDs (32). Furthermore, in thepsychodynamic theory the therapeutic agentdepends on the conscious use of the relation-ship and not simply on single techniques.

The disadvantage of using broad tecniques isthe likelihood of including elements which arenot so essential in the treatment plan. On theother hand, currently it is not clear which arethe most effective treatments for AN (4).

Goals of treatment are both nutritional andpsychological. The first include nutritionalrehabilitation, weight gain, modification of dis-turbed eating behaviours, and identification of

e32 Eating Weight Disord., Vol. 14: N. 2-3 - 2009

TABLE 1Brief Adlerian Psychodynamic Psychotherapy (B-APP).

Referencial paradigms Objects Elements of the therapeutic process

Individual = psychosomatic unity integrated in the society Resolution of the focus problem Establish encouraging relationship with the therapist

Individual = build and regulate self’s image Decrease/non-increase of symptoms Identify the focus; relate symptoms with currentlife situation

Bond and symbolic patterns regulate human relationships Increase of subject’s quality of life Detect, in the focus problem, the areas for possiblechanges

TABLE 2The week’s organization of the Turin treatment day hospital.

Day hospital for eating disorders: A review

perpetuating factors. The latter include anincrease of patients’ awareness of the disorderand of motivation to treatment, a psychody-namic understanding of symptoms, a deeperawareness and understanding of emotions, animprovement in relational skills and socialadjustment, self-esteem and mood regulation.

The treatment programme aims to enhancethe maturation of personality together with thechange of symptomatic behaviours. The core oftreatment is represented by the association of atherapeutic work focused on personality and onthe eating disordered symptom together with atreatment setting where patients live, work andeat together. Another important element is thework on family and with the family (counseling).

Individual psychotherapy (weekly sessions)with a psychodynamic Adlerian orientationoffers patients an opportunity of reflection andelaboration of their experiences.

Group psychotherapy sessions take placeevery day and enhance the expression of emo-tions. The group setting allows to work on therelational dynamics which take place hic etnunc. This is particularly relevant in patientswith EDs, who have difficulties in recognizingand understanding their emotions and buildingsignificant and intimate relationships. The elabo-ration of patients’ experiences and the mirroringand empathic identification mechanisms activat-ed by group therapy increase patients’ coopera-tion skills and reduce their competitiveness.

The psychodynamic approach could also beuseful to strengthen patients’ improvementafter discharge, as described for outpatientswith other psychiatric disorders (33, 34).

The Turin DH can treat about ten patients atthe same time. Patients are admitted after diag-nostic sessions and after signing a behaviouralcontract; they are usually referred from outpa-tient units, previous failed treatments or frominpatient care. Inclusion criteria are a Diagnos-

tic and Statistical Manual of Mental Disorders -fourth edition (DSM-IV) diagnosis of ED, eitherAN or BN, medical stability and a body massindex (BMI) >13.5 kg/m². Patients must showmotivation for treatment and have some capac-ity to relate in a group setting. Exclusion crite-ria are an acute suicide or medical risk, sub-stance abuse or dependence, comorbid psy-chotic symptoms or BMI<13.5 kg/m². Patientswith a BMI <13.5 kg/m² are excluded becauseinpatients treatments is more suitable for theseverity of their clinical status.

The average length of stay is 24-26 weeks,from Monday to Friday for about 7 hours perday. In DH, patients eat lunch and a snack inthe mid-morning with the assistance of nursesand dietician (assisted eating), who help andsupport patients facing difficulties duringmeals. All patients have an individually bal-anced meal plan prescribed by the dietician.Patients are weighed in underwear before thesnack, from three times to once a week; whenunderweight, their target weight is set individ-ually and the medical staff can decide whetherto use or not intravenous feeding.

The staff consists of a psychiatrist, 2 half-daypsychiatrists, a half-day clinic psychologist, 2psychiatry trainees, 5 nurses, a dietician, a con-sultant nutritionist, a consultant supervisor anda consultant music therapist. Every week a con-sultant nutritionist evaluates patients’ physicalhealth status. Psychiatric drugs (antidepres-sants, antipsychotics, BDZ and mood stabilis-ers) for comorbid psychiatric symptoms(depression, anxiety, mood instability) are pre-scribed when indicated.

RESULTS

Eighteen suitable articles and two reviewswere analyzed. The main features of each cen-

e33Eating Weight Disord., Vol. 14: N. 2-3 - 2009

Monday Tuesday Wednesday Thursday Friday

8.30-9.30 Welcome and Welcome and Welcome and Body image therapy Welcome andpharmacologic therapy pharmacologic therapy pharmacologic therapy phfarmacologic therapy

9.30-10.30 Dietistic visits Individual psycotherapy Music therapy Nutritional visits Cognitive behaviouraltecniques

10.30-11.00 Assisted snack Assisted snack Assisted snack Assisted snack Assisted snack

11.30-12.30 Psychodinamic group Psychodinamic group Psychodinamic group Psychodinamic group Psychodinamic group

13.00-13.45 Assisted eating Assisted eating Assisted eating Assisted eating Assisted eating

14.00-15.00/30 Psychiatric visits Reading group Creative group Psychiatric visits Recreation


tre included in this study are listed in Table 3.The DCP in Freiburg and the CC in Edin-

burgh are the only centres treating ED patientstogether with patients suffering from otherpsychiatric disorders.

The main variables of the centres studied arethe following:•Main features of the programmes:

- the centres opened in different years (from1980 to 2006);

- treatment orientation: cognitive behaviouralin most cases (9/11), psychodynamic in 2/11cases. The WPH began as psychodynamicbut after 4 years turned to cognitive behav-ioural;

- duration of treatment: highly variable, from3 to 39 weeks (mean 15,04 weeks; standarddeviation=10,22);

- behavioural contract: in all centres exceptfor CC and DTP.

•Treatment goals: modification and normalisa-tion of eating behaviour (10/11), nutritionalrehabilitation and weight gain (8/11), relapseprevention (3/11), promotion of autonomy,social adjustment, self-control and self-esteem(4/11), understanding of symptoms (4/11),identification and resolution of perpetuatingprocesses (6/11), reduction of over-evaluationof shape and weight (5/11).

•Group activities:- treatment type: mostly group (5/11), only

group (2/11), group and individual (4/11);- treatment tools: bio-psycho-social frame-

work (6/11) and cognitive behaviouralgroups (10/11) are the main treatment tools.

• Issues addressed in individual and groupactivities:- body attitude: (missing for CC) body-image

group (10/11) in every centre, often associat-ed with other body-shape oriented activities;

- coping skills: the most common activities areassertiveness training (6/11) and social skillstraining (4/11);

- interpersonal functioning: (missing for CCand DCP) group work on interpersonal rela-tionship (6/11), interpersonal psychotherapy(2/11), “Yalom” group (1/11), “Good bye”group (1/11);

- nonverbal expression: art, creative and mu-sic therapy (9/11);

- family functioning: all the centres involvefamily in treatment (missing datum for DCP)and the most common approach is familytherapy (6/11);

- other issues: housing facilities (2/11), EDpatients with other psychiatric patients(2/11), vegetarian menu (1/11), operantbehaviour methods (10/11), residence groupwith apartment-like housing (1//11), explicit

use of operant principles and of mindfulness(1/11), recreation (2/11), 2-day camp (1/11),readiness and motivational therapy (1/11),structural process-model and related skills(1/11); CC is close to shops and restaurants.

•Follow-up:- only five centres perform a follow-up (5/11):

outpatient support group (1/11); monthlyoutpatients visits (1/11); weekly group thera-py sessions (2/11); weekly individual psy-chotherapy for 6 months (1/11); weeklyrelapse prevention group (1/11).

Other variables studied (not listed in tables)are:•Conditions for admission:

- inclusion criteria: diagnosis of ED accordingto DSM-IV criteria (6/11), failure of previoustreatments (3/11); motivation to change/fortreatment (7/11); medical stability (3/11);capacity to relate in a group (4/11);

- exclusion criteria: suicide risk (10/11), med-ical risk (6/11), substance dependence (8/11),psychosis (4/11).

•Treatment of eating disordered behaviours:meal plan (9/11), assisted eating (6/11), self-monitoring (5/11), nutrition group (8/11), psy-choeducation (4/11), CBT (7/11), cooking(4/11).

•Day treatment is part of a larger eating disor-der programme in all centres (11/11).

•Group size: from 5 to 20 (mean 9,8; standarddeviation 3,68); missing for CC.

•Group structure: half open (1/11), closed(1/11), open (7/11); missing for CC and DCP.

•Days a week: three (1/11), four (3/11), five(7/11), seven (1/11). The WPH has 5-day or 3-day treatments; the DHP in the years 1995-2000 lasted 4 days/week.

•Patients’ features:- diagnosis: mostly AN (3/11); mostly BN

(1/11); only BN (1/11); AN, BN and ED nototherwisw specified (EDNOS; 1/11). Missingdatum for five centres;

- average duration of patients’ illness: from4.19 to 9.4 years (7.42±1.86 years). Missingdatum for five centres;

- BMI: highly variable according to the rate ofanorexic and bulimic patients, from 17.03 to23.9 kg/m² (20.49±2.41 kg/m²). Missingdatum for five centres.

•Weight control: (missing for CC and DCP)daily weighing (3/11), weighing group (2/11),weekly weighing (3/11), individual weighing:3, 2, 1 time/week (2/11).

•When underweight: most centres (8/11) fix anobjective for weight gain/week (which can varyand in the DHP is fixed only for anorexics); liq-uid nutritional supplements (2/11); individualtarget weight range (2/11).




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•Pharmacotherapy: missing datum for DCP;most centres except for TCE use psychiatricmedication when indicated (9/11).

•Physical issues: medical monitoring (7/11); notmentioned in four articles.

•Staff: all centres have a multidisciplinary team(no data for EDP and OAEDS) with 7 to 15members.

•Treatment planning: community meeting fortreatment plans (5/11); weekly supervisionmeeting (1/11); goal setting (4/11); multidisci-plinary ward meeting (1/11).

•Group functioning: community meeting (5/11);patient-staff meeting (4/11); Friday meeting tofix weekend nutritional goals (1/11).

•Tests: (missing in three centres) assessment isperformed with different tests at admission(7/11), discharge (6/11) and follow-up (3/11).

DISCUSSION

The DH programmes of the eleven EDs spe-cialised centres reviewed share some featuresbut also show many differences, suggestingthat DH programmes are still largely experi-mental and that each centre plans its own pro-ject on the basis of some core issues which areintegrated with clinicians’ experience andknowledge. This approach to DH treatmentplanning is not wrong tout court, but it limitsthe comparison of the different centres and athorough understanding of what is really effec-tive in the treatment of EDs.

Significant evidence about DH treatment effi-cacy for EDs and a “gold standard” for inten-sive DH treatment are still missing.

Recently Fairburn (35) proposed a DH pro-gramme driven by a treatment very focused oncore symptoms, according to his transdiagnos-tical approach (36). This seems an interestingway to discriminate whether very focusedtreatments are better than individualised onesusing several techniques. Unfortunately modelslike the one suggested by Fairburn require acareful selection of patients and share the samelimits as trials involving EDs patients (32, 37).

However, some shared elements can be iden-tified in most DH treatment programmes,which are likely to represent the main core oftheir therapeutic effect.

Elements shared by DH programmesFrom a clinical point of view, all centres

share an intensive work on eating symptoma-tology, either within the context of a cognitive-behavioural model or with cognitive-behav-ioural techniques. Discussion groups, mealplan and several types of meal monitoring are


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the main treatment tools. The behavioural con-tract (which can show different degrees ofstrictness) (10) and motivation assessment areconsidered necessary by all centres.

The importance of motivation is supported bythe growing number of studies in literatureabout the prognostic importance of the assess-ment of patients’ stage of change and motiva-tion (38). Another shared issue is body imagetherapy, since body image disturbances play arelevant role in maintaining EDs. Body image isalmost always disturbed in ED patients (5, 39,40) and dissatisfaction with body image is apredictor of suicide attempts (41). The increasein body weight during DH treatment canincrease patients’ difficulties with their bodyimage, if these are not properly addressed (42).

Another relevant issue for treatment is familyinvolvement, which can take place in differentways. The onset of EDs often takes place dur-ing adolescence and parents of ED patientsshow some typical relational and personalitypatterns at the questionnaires, which mightplay a pathogenic role (43, 44). Outpatients tri-als showed the efficacy of family therapy (45).As regards DH treatment, the family needs helpto understand and support patients’ psycholog-ical, physical and eating changes. On the otherhand, patients’ understanding of family dynam-ics is part of the therapeutic process (46).

As regards group functioning, all the centresexcept one (including 20 patients) work withsmall groups (8-12 patients) and share the opin-ion that this is the proper number of patients toallow positive group interactions and to workon individual problems (10).

Differences among DH treatmentsGiven the shared issues discussed above, one

would expect not to find relevant differencesamong the centres. Nonetheless, differencesare several.

Only few centres fix a BMI. Overall, theimpression is that decisions about BMI aremade according to patients’ clinical assess-ment. Since a low BMI predicts the failure ofDH treatment (47), it should be carefullyaccounted for. Other inclusion criteria are con-tradictory: for example, three centres requirestable clinical conditions, while another acceptspatients undergoing a fast weight loss.

Only four centres mention the assessment ofpatients’ capacity to relate in a group settingand this suggests that group relational dynam-ics are not always properly accounted for.

Moreover, most centres work with patientswho have failed to respond to other treatments,while other ones accept patients when a DHtreatment is recommended, also as first treat-

ment attempt. In some cases patients areadmitted in DH after discharge from inpatienttreatment, making DH a sort of “prolongation”of care in the context of a wider stepped careprogramme.

The most striking difference is the durationof DH treatment, which ranges from a mini-mum of 3 weeks to a maximum of 39. A criticalreview of data identifies 7 centres treatingpatients for 2-3 months and 4 centres treatingpatients for 6-9 months. This suggests thehypothesis that, despite the shared elementsdescribed above, two different levels of treat-ment intensity exist in DH care. A first model ofDH has a shorter duration and is mainly symp-tom-focused while a second one has a longerduration and is focused on patients’ relationalskills, psychodynamic symptom understandingand more gradual changes in body weight. Thishypothesis is supported by the fact that the 4centres with a longer treatment duration workalso with individual psychotherapy, while 6 outof the other 7 centres work mostly/only withgroup therapy. Moreover, it is likely that short-er treatments address patients in less severeconditions.

Differences in treatment intensity emergealso in the number of days/week, ranging from3 to 7 days/week of DH treatment.

The approach to eating disordered and com-pensation behaviours is included in all DHtreatment programmes and though some basicprinciples are shared, it is quite different fromone centre to another. Some adopt a more con-trolling approach, while others promote auton-omy; several self-monitoring techniques areused and some centres include activities asbuying and cooking food. No univocal indica-tions exist for the frequency of weight con-trols/week.

Though the importance of dieticians’ work isacknowledged and despite the AmericanDietetic Association guidelines (48), it is notclear which are the best techniques to use.

DH programmes use a variety of techniquesfor social skills and creative activities, includingassertiveness training, mindfulness training,dance therapy and different types of art thera-py. Each centre makes its own choices accord-ing to theory of reference and availableresources, but these activities do not seem toplay a specific therapeutic role. Their meaningseems to be that of supporting and lighteningthe symptom-focused interventions which oth-erwise would be monothematic and oppressing.

A last consideration is that no centre per-forms interventions addressing perfectionism,and despite its widely acknowledged role in thepathogenesis of EDs (35, 36, 49, 50) this psy-



chopathological core is often unchanged afterDH treatment (42).

Treatment goalsA particular attention must be paid to treat-

ment goals. Apart from the Edinburgh CC,which lacks recent publications, almost all cen-tres share the objective of weight normalisationor weight gain and of modification/norma-lisation of eating behaviour. Only 4 centres outof 11 work specifically on ED perpetuating fac-tors and relapses.

As regards psychological and behaviouralobjectives, there are several differences. Somecentres (4/11) focus attention on the psychologi-cal issues of self-esteem, control and autonomy,according to the cognitive theory about EDs.Other centres underscore the importance of thepsychodynamic or cognitive understanding ofthe symptom itself (5/11), which is relevant fortheir healing process (46). Last, other centresunderscore the need to improve social (3/11) andfamily (2/11) functioning.

Differences in treatment goals seem to reflectthe different emphasis the centres pose onintrapsychic dynamics, relational dynamics andsocial issues.

In conclusion, the work on symptoms is con-sidered an essential and primary objective, butall centres share the opinion that the intensivetreatment of patients is not complete if otherissues than symptoms are not addressed.

ConclusionsThe DH therapeutic programmes reviewed do

not allow to identify univocal guidelines for typeof intervention, treatment intensity and dura-tion. A consensus conference of experts isrequired to define some shared concepts inorder to make DH treatment programmes morehomogenous, measurable and comparable.

Overall, two types of DH treatment can beidentified: a shorter, more symptom-focusedone, and a longer, more person-focused one.

In both cases, attention needs to be paid topatients’ selection, motivation to change andidentification of treatment goals. Coherenceamong treatment model, treatment tools, sever-ity of clinical status and treatment goals needsto be carefully checked.

Moreover, attention to patients’ groupdynamics, equipe group dynamics andpatients/staff dynamics needs to be under-scored and emphasised.

A focus on psychodynamic formulation andresistance to treatment is needed in those cen-tres with a psychodynamic approach and aspecific attention on group dynamics (51). Per-sonalisation of treatment programmes should

consider the study and assessment of personal-ity (52), which is a specific treatment tool of theTurin Centre.

In a multi-disciplinary équipe only somemembers have a psychological training, andthe supervision on group dynamics is neces-sary to increase the relational awareness ofequipe members. How one talks to patients canbe therapeutic or iatrogenic but the importanceof this fact is often underestimated by modernpsychiatry. Indeed, it is necessary for each staffmember to share and discuss his/her impres-sions, emotions and behaviours with the otherones in order to modulate his/her treatmentapproach.

Last, further studies about outcome and fol-low-up of DH treatment are required.


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Day hospital programmes for eating disorders: A review of the similarities, differences and goals